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Full text of "U.S. Navy Medicine Vol. 70, No. 2 February 1979"

VADM Willard P. Arentzen, MC, USN 

Surgeon General of the Navy 

RADM H.A. Sparks, MC, USN 

Deputy Surgeon General 

Director of Public Affairs 

ENS Richard A. Schmidt, USNR 

Managing Editor 

Ellen Casselberry 

Assistant Editor 

Virginia M. Novinski 

Editorial Assistant 

Nancy R. Keesee 



Contributing Editors 
Contributing Editor-in-Chief : CDR E.L. 
Taylor (MC); Aerospace Medicine: 
CAPT M.G. Webb (MC); Dental Corps: 
CAPT R.D. Ulrey (DC); Education: LT 
R.E. Bubb (MSC); Fleet Support: LCDR 
J.D. Schweitzer (MSC); Gastroenterol- 
ogy: CAPT D.O. CasteU (MC); Hospital 
Corps: HMCM H.A. Olszak; Legal: 
LCDR R.E. Broach (JAGC); Marine 
Corps: CAPTD.R. Hauler (MC); Medi- 
cal Service Corps: CAPT P.D. Nelson 
(MSC); Nephrology: CDR J.D. Wallin 
(MC); Nurse Corps: CAPT P.J. Elsass 
(NC); Occupational Medicine: CDR J.J. 
Belianca (MC); Preventive Medicine: 
CAPT D.F. Hoeffler (MC); Research: 
CAPT J.P. Bloom (MC); Submarine 
Medicine: CAPT R.L. Sphar, (MC) 



POLICY: U.S. Navy Medicine is an officii! publication 
of the Navy Medical Department, published by tile Bureau 
of Medicine and Surgery. It disseminates to Navy Medical 
Department personnel official and professional information 
relative to medicine, dentistry, and the allied health sci- 
ences. Opinions expressed are those of the authors and do 
not necessarily represent the official position of the Depart- 
ment of the Navy, the Bureau of Medicine and Surgery, or 
any other governmental department or agency. Trade 
names are used for identification only and do not represent 
an endorsement by the Department of the Navy or the Bu- 
reau of Medicine and Surgery. Although U.S. Navy Medi- 
cine may cite or extract from directives, official authority for 
action should be obtained from the cited reference. 

DISTRIBUTION: U.S. Navy Medicine is distributed to 
active-duty Medical Department personnel via the Standard 
Navy Distribution List. The following distribution is author- 
ized: one copy for each Medical, Dental, Medical Service 
and Nurse Corps officer, one copy for every 10 enlisted 
Medical Department members. Requests to increase Of de- 
crease the number of allotted copies should be forwarded to 
U.S. Navy Medicine via the local command. 

CORRESPONDENCE: All correspondence should be 
addressed to: Editor, U.S. Navy Medicine. Department of 
the Navy, Bureau of Medicine and Surgery (Code 0010), 
Washington, D.C. 20372. Telephone: (Area Code 202) 2S4- 
4253. 254-4316. 254-4214; Antovon 294-4253, 294-4316. 294- 
4214. Contributions from the field are welcome and will be 
published as space permits, subject to editing and possible 
abridgment. 

The issuance of this publication is approved in accordance 
with Department of the Navy Publications and Printing 
Regulations (NAVEXOS P-3S). 



U.S.NAVY 




Vol. 70, No. 2 
February 1979 



1 From the Surgeon General 

2 Special Report 

Surgeon General's Conference for Commanding Officers 
2 Opening Remarks 

VADM W.P. Arentzen, MC, USN 
5 Managing Fiscal Assets 

RADMA.C. Wilson, MC, USN 

7 Issues in Medical Program Planning 
VADM W.N. Small, USN 

8 Medical Support for the Marines 
LGENL.F. Snowden, USMC 

10 Medical Support and the Logistician 

VADM T.J. Bigley, USN 
12 Medical Care: The Beneficiaries' View 

R. W. Nolan 
14 Learning to Communicate 

RADM D.M. Cooney, USN 
18 Medicine and the Law 

RADM C.E. McDowell, JAGC, USN 

21 Operational Planning 
CAPT J.J. Quinn, MC, USN 

22 Concerns of the Enlisted Community 
HMCM H.A. Olszak, USN 

25 A Special Role 
HON. Edward Hidalgo 

26 The Navy Personnel Situation 
VADM R.B. Baldwin, USN 

28 Notes and Announcements 

29 BUMED SITREP 



COVER: At the Surgeon General's annual conference for com- 
manding officers, HMCM H.A. Olszak, USN, Force Master Chief, 
BUMED, detailed current concerns of the enlisted community. For 
his presentation, see page 22. 



NAVMED P-5088 



From the Surgeon General 



Cost Containment is a Personal Responsibility 



The same pressures which have 
resulted in the cost of medical care 
in the civilian community increasing 
by over 1250% since 1950 are re- 
flected just as dramatically in the in- 
creasing costs experienced in the 
operation of the Navy Medical De- 
partment. Changes in technology, 
new diagnostic and therapeutic 
modalities, imposition of new life 
and safety codes, newly mandated 
health surveillance programs, utility 
costs, wage increases, inflation, as 
well as heightened expectations on 
the part of those for whom we pro- 
vide health services have all con- 
tributed to driving the total eco- 
nomic value of the resources we re- 
quire to a level never before experi- 
enced. Unfortunately, the economic 
resources which have been made 
available to support our system 
have not been sufficient to meet the 
increased resource demand which 
we are experiencing; competing as 
they must against all government 
programs in these times of conflict- 
ing imperatives. 

Never before has it been more 
vital that we in Navy medicine 
explore every avenue possible to 
reduce our costs and also to ensure 
that the resources we do expend are 
contributing maximally to providing 




both the quality and quantity of 
services necessary to accomplish 
our mission. 

I have been impressed by the ini- 
tiatives which have been taken to 
ensure optimal use of our resources. 
Many commands have formed cost 
containment committees at the local 
level. Active utility conservation 
programs have paid dividends far 
beyond even optimistic expectations 
in terms of fuel conservation and 
dollar savings. Improved inventory 



management has resulted in signifi- 
cant savings in many commands. 
Development of alternative cheaper 
sources of purchase for many of our 
high usage expendable items is 
reducing operating costs for many 
of our facilities. 

However, it is not only at the 
command level that attention must 
be directed to cost containment. 
Each of us in the Medical Depart- 
ment, no matter what his job, must 
take it as a matter of personal re- 
sponsibility to manage the re- 
sources he uses as carefully as pos- 
sible. Look at your job. Can it be 
done in a manner which will save 
dollars or people, at the same time 
continuing to contribute maximum 
effectiveness from our efforts? I am 
certain, based on the resourceful- 
ness that each of you has demon- 
strated so fully in the past, that an 
increased effort on everyone's part 
will provide the savings and, there- 
fore, the resources needed to do our 
job. 



V 



/ 



1 




W.P. ARENTZEN 

Vice Admiral, Medical Corps 

United States Navy 



Volume 70, February 1979 



Special Report 



Surgeon General's Conference 
for Commanding Officers 



The Surgeon General's conference for commanding 
officers of medical and dental commands convened this 
year in Arlington, Va., 13-15 Nov 1978. 

This report represents an edited — sometimes para- 
phrased or abbreviated — version of major speakers' 
presentations at plenary sessions of the conference. 
Their remarks do not necessarily reflect official views of 
the Navy Department or the naval service at large. — 
Ed. 



Opening Remarks 

VADM W.P. Arentzen, MC, USN 
Surgeon General of the Navy 



Let me start by sharing this little aphorism with you: 
"Life is easier to take than you'd think: All that is 
necessary is to accept the impossible, do without the 
indispensable, and bear the intolerable." The past two 
years have shown me the truth of this statement. 

The Medical Department has many problems — many 
and serious problems — but its future is bright. It has a 
future because that future is to a large extent in the 
competent hands of you, the commanding officers and 
senior staff. 

Where are we, and where are we going? 

First, let's emphasize the concept of a Medical De- 
partment. That is what we are. We should not, we must 
not, we cannot think primarily of "Corps." As we must 
think of "one Navy," putting aside preeminence of air 
or surface or submarine or active vice reserve, so must 
we subvert our just pride in "Corps" to the singular 
product of health care delivery that none of us can 
deliver alone. 



"One Navy" is the watchword of the CNO. It is with 
considerable pleasure we note that we, as a Medical 
Department, anticipated him by several years. 

The Medical Department's mission is unique. We 
must protect, defend, and justify that uniqueness. Most 
modern medicine is the same wherever you go. But 
there are things in the military that are different, and 
they must be preserved. 

We must remain an integral separate system, be- 
cause only then can wc meet the current contingency 
scenarios. And only if we maintain full-service facili- 
ties, with teaching programs to back them up, will we 
have the immediately available assets that contingency 
would demand. We must justify, in a credible manner, 
all of our billets to contingency and convince the ana- 
lysts of what we already know: that to say "a doctor is a 
doctor under any circumstances" is a fallacy. 

Admiral Win Weese, in a recent presentation to 
DOD, refuted that statement. He said that a civilian 
physician cannot just drop his practice in a contingency 
and serve in the Navy. He must be trained — for a Navy 
physician must know more than his civilian counter- 
part. "What do we civilians know about war wounds, 
massive injuries, mass casualty evacuation, logistics, 
etc.?" he asked. "Perhaps we have placed too much 
emphasis on how similar we are to civilian medicine — 
especially in our hospital environment." 

We must emphasize the challenge and excitement of 
planning, training for contingencies, trauma research, 
operational medicine, CBR, cold weather medicine, 
infectious diseases, environmental medicine, aviation 
and space medicine, submarine medicine, etc. And 
what a fertile field for preventive dentistry — an oppor- 
tunity unequaled in civilian life! 

Assets and programs. What is the status of the assets 
of our Medical Department? 

The Medical Corps has experienced a significant 
shortfall. The all-volunteer concept has not lived up to 

U.S. Navy Medicine 



the promises of its optimistic supporters, and we are 
almost 200 physicians short of our allowable end- 
strength. That is less than half the shortfall predicted 
but a year ago, and represents about 5%, not 10%, of 
the authorized end-strength. 

The real problem lies in the specialty mix. While 
enjoying our needed numbers in some areas, we are 
pitifully shy of them in some others, such as orthope- 
dics, OB-GYN, radiology, and flight surgery. These 
shortages are being addressed through a number of 
avenues: 

• FAC "U" coding has enabled us to maximize utili- 
zation and still keep many operational billets, notably 
with the Marines, covered. 

• The "Adak Plan" has enabled us to see that qual- 
ity coverage is shared with remote areas, and even air- 
craft carriers, where the need exists but utilization is 
limited, 

• Some vertical cuts, such as a series of OB-GYN 
services where CHAMPUS was available, have had to 
be instituted. 

• The expansion of the family practice module and 
panel to the aviation community has been a move of in- 
calculable mutual benefit. 

• Recognition of the emergency service physician, 
and training and recruiting of these specialists, will 
release other assets to their primary field of specializa- 
tion. 

• The quality of our recruits has markedly improved 
over the past 12 months, and the scholarship program 
has been fully subscribed. When in a few short years 
the output of that program is combined with our share 
of the graduates of the Uniformed Services University, 
our numbers problem will be solved. 

The Nurse Corps has increased its retention percent- 
age to 60%. Recruiting programs have been developing 
a high yield of quality nurses, and a program is under 
way to justify an increase in the number of nurse billets 
— an increase I know is justified by the change in em- 
phasis of care to more sophisticated nursing, use of 
nurses as practitioners, shift in patient loads to outpa- 
tient services, and augmented patient counseling and 
education. 

For the first time in recent memory, the Dental Corps 
faces a potential shortfall. More emphasis must be 
placed on dental officer recruiting to erase the shortfall. 
These efforts will be closely watched. Should recruiting 
fail, restoration of the scholarship program will follow 
as a must. 



Sophistication of the various aspects of health care 
administration has prompted potentially sweeping 
changes in career patterns for the Medical Service 
Corps, These advances require more training and edu- 
cation, and this need in turn is being met by the institu- 
tion of three new course curricula at the Naval School of 
Health Care Administration: an advanced health policy 
and planning course, a patient services administration 
course, and a course in advanced finance and supply. 
These careers within a career are attracting talented, 
bright, and dedicated candidates whose futures arc 
being ensured by patterns of advancement never before 
made available. 

Additional pharmacists have been recruited, and we 
are in the process of recruiting audiotogists. In the very 
near future, social service workers will be recruited into 
the Medical Service Corps. 

The health care administration field is now so com- 
plicated that the time has arrived for specialization. A 
plan has been drafted to permit specialty fields of 
finance, information management, supply, and patient 
affairs, in addition to general administration. These will 
allow for career progression and promotion while re- 
maining specialized. Our experienced finance officers 
will now remain where they are needed — in finance — 
and will still have a chance for 0-6. 

The Hospital Corps is undergoing scrutiny to estab- 
lish more equitable rotation, particularly of specialized 
staff. The revitalization of the Physician's Assistant 
Program, whose ranks will be filled by tapping the 
highly capable advanced hospital corpsmen, will go a 
long way to alleviate the impact of our shortages. 

"One Navy" speaks not only to the earlier mentioned 
communities on the active-duty side but refers to the 
Reserves as well. 

Too often and too long, the Reserves have been given 
patronizing lip service until the time of crisis, when 
they come to swell our ranks and lend their talents and 
their lives, if necessary, to assure the success of our 
mission. No more. These dedicated Reserves deserve 
more from us. and if and when that time of crisis 
recurs, we will need their trained and dedicated sup- 
port again. They deserve to be shortchanged no longer. 
We can give them no less than our best — for that is 
what we require of them. 

Environmental and industrial medical problems are 
increasing daily. They require more and more of our 
resources. Still, the shipyard commanders are not 
satisfied. And we have only scratched the surface of the 



Volume 70, February 1979 




Many issues were studied. 



levels from prior years must be achieved through care- 
ful analysis of requirements and full justification for a 
new program, or a change in an existing program — in- 
cluding a careful evaluation of any offsetting costs. 

It is not enough any more merely to say "I need this 
or that" or "My workload keeps increasing." Changes 
must be documented at all levels. 

The balanced-budget concept should force you to re- 
evaluate existing programs to assure yourself that the 
programs are not only necessary but are properly 
planned and properly executed, in terms of resources 
expended against workload. 

In the preparation of any upcoming year's budget, 
the history of the resource execution for the year im- 
mediately past is of prime importance. 

During the preparation of the budget, the Bureau 
makes commitments for certain actions — promises, of a 
sort, that our resource execution plan will fall into a 
given pattern. If, in the execution of your annual 
budget, you significantly deviate from the financial 
plan you submitted, which was approved, it would 
adversely affect our credibility with the Navy Comptrol- 
ler and could possibly have the same effect on your 
credibility with the Bureau. 

This is not to say that changes cannot or should not 
be made after budget execution has started, but the 



rationale must be apparent and justifiable to everyone 
concerned. Our collective credibility is of enormous 
importance in the acquisition of resources to carry on all 
Medical Department activities. 

The system that requires you to report to the Bureau 
is also the one that allows the Bureau to report Bureau- 
level budget executions in a timely fashion to higher 
authorities. We are attempting to improve the manage- 
ment information system in the Medical Department, 
particularly through the application of data processing 
systems, so that we can reduce some of your report 
preparation burden. We are well aware that the report- 
ing requirement is one of your biggest problems in 
terms of people and time — and, for some of you, even 
in terms of getting the reports to us after they are 
made. 

The BUMED reporting requirements to higher 
authority are of such critical nature that the timeliness 
of our reporting, based on your report, frequently 
makes a great deal of difference in the competition with 
other major claimants over budget adjustments during 
the execution year. 

I think I ought to pass along another little fact that 
may not be too well understood. The entire government 
watches us but, in addition to being interested in the 
amount of resources provided for our medical services. 



U.S. Navy Medicine 



our financial colleagues in the Navy and in DOD and 
OMB are equally interested in the rate of obligation of 
these resources. They not only watch how much we get 
but also want to know at what rate we spend it. If one 
looks at the DOD budget, one is immediately struck by 
the fact that the rate at which these monies are obli- 
gated has an enormous impact on the nation's econ- 
omy. 

Monitoring. Tracking the rate of obligation of re- 
sources is one of the mechanisms by which the perform- 
ance of the government at large, and the Bureau in 
particular, is monitored. But there are other ways in 
which Medical Department resource execution is moni- 
tored. One such way is looking at the migration of funds 
between various expense categories. For example, if 
significant O&MN dollars migrate into the maintenance 
of real property in comparison with planned mainte- 
nance funding, this makes our plan suspect, especially 
if we have defended the need for O&MN dollars that 
migrated. Frequently, dollars migrate from mainte- 
nance projects to minor construction projects or minor 
equipment projects. 

In many instances, as I suggested earlier, the Bureau 
may have made specific commitments to the Navy 
Comptroller to take reductions to comply with fiscal 
constraints. When the budget execution reports fail to 
show that we did what was promised (I would remind 
you that these promises were based on financial plans 
submitted from your activities), our collective financial 
credibility is at stake. 

Some reports involve mistakes in the categories of 
expense assignments. For example, a year or so ago, 
the Navy Comptroller threatened to take away some of 
our travel dollars because they were incorrectly re- 
ported, giving the budget monitors a false impression. 

It is important that communications between the field 
activities and the Bureau be effective, complete, and 
continuous. Problems always arise during the budget 
execution phase, but the earlier the problem is identi- 
fied and quantified, the better we can assist your activ- 
ity in solving it and preventing future difficulty. For 
example, if you perceive an increase in your laboratory 
workload, such information should be the basis for you 
to reevaluate your plans and notify the Bureau that you 
have such a problem. Similarly, any increase in specific 
costs, such as utilities or other externally controlled 
costs, should be recognized and reported as soon as 
possible. By so doing, you make the Bureau aware of 
the problem for the whole department, not only for your 
activity. 

What I've said speaks to a future with greater con- 
trols and less flexibility. But, simply stated, we are 
being asked and directed to plan carefully, to make 
effective use of our resources, to execute them accord- 
ing to the financial plans, and then to report that we 
have done so. That's really just good management. 

It's our job to manage well — it's never been less than 
that. 



Issues in Medical Program 
Planning 

VADM W.N. Small, USN 
Director, Navy Program Planning 

Thank you for inviting me today. Theoretically, I'm 
one of the few people in OPNAV who is not an advocate 
of any particular thing. My associates and I, in the Of- 
fice of Program Planning, tend to be looked on as being 
for nothing and against everything, but really what we 
do is provide a check and balance, to make sure that our 
programs are validated and can be defended when the 
priorities are all put together. 

With respect to the Medical Department and our 
tasks in the programming and budgeting cycle, the 
most important thing we must do is articulate, in a 
manner that we all understand, what the Navy's con- 
cept of health care really is. 

Many people — the Secretary of the Navy, OSD, and 
even those of us in the line Navy — have very definite 
perceptions of their own as to what Navy health should 
be. Even though I've been educated by VADM Arent- 
zen and others, I must conclude that I have not yet 
come to an understanding of the total complexity of this 
issue. I recognize that readiness for contingency opera- 
tions is the number one mission of the Medical Depart- 
ment, as it is for those of us in the general line; but how 
that contingency mission is going to be executed, and 
what the state of training and readiness of people and 
equipment to carry it out should be, I frankly can't state 
in program terms. A great deal of effort has been made 
in the past year to provide a vehicle — a plan of 
action — that will explain to those outside your field 
exactly what that concept comprises, including the pro- 
cedures by which contingency operations will be exe- 
cuted. 

The use of the Naval Reserve, like all other aspects of 
this problem, is also a very hard issue to define. I'm not 
too sure — having just participated peripherally in 
"Nifty Nugget," the worldwide mobilization exercise 
we went through — that we really know what the capa- 
bility of the Naval Reserve is, specifically to backfill the 
hospitals when the active-duty personnel deploy on 
contingency operations. That's a total-force issue, but it 
also has major financial implications in your effort to 
develop a coherent Navy program plan for the Medical 
Department. 

Standards of quality often come up in my arena when 
we talk about budget requirements, and BUMED must 
learn to state its requirement in a form that has mean- 
ing other than dollars and cents. When we talk require- 
ments in terms of dollars alone, it has very little mean- 
ing. What we need to know is: What does the program 
represent qualitatively? What is the impact of not 
having that program executed? We must establish a 



Volume 70, February 1979 



baseline in terms of quality which will have credibility 
in defending budget increments in the medical area. In 
this context, we must define the relationship between 
professional medical personnel and lay personnel? 
What is a good ratio of physician's assistants or para- 
medics to the requirement for fully competent, board- 
certified specialists? What is the responsibility of the 
Medical Department for what I call social issues? We 
seem to have an increasing requirement for counselors 
and other people to handle not only the "abuse" kinds 
of problems, but also a rapidly burgeoning area of 
occupational safety and hazards. 

An issue I often hear debated within my own shop 
concerns the orientation of medicine to operational fleet 
support or to the teaching hospital. I know VADM 
Arentzen has very strongly stated his direction that the 
primary orientation of Navy medicine should be to sup- 
port the fleet. It's an interesting and important issue, 
because the regionalization of facilities and capitation 
budgeting seem to work counter to that — and that's a 
very parochial view of my own. I do think this trend, at 
least in the perception of the line officer, tends to 
diminish fleet support. From the budget standpoint, 
we're going to be pushed harder and harder to do more 
and more consolidating, and we must not fail to 
recognize, at the same time, the resulting impact on our 
own people. 

A similarly large and emotional issue is CHAMPUS 
versus inside care for Navy beneficiaries. VADM 
Arentzen and all of the staff have been very active in 
trying to get the percentile payments for CHAMPUS 
up, to make that alternative a little more attractive to 
our folks. Again, this is an issue that has many protago- 
nists, each with a different axe to grind. All I can say is 
that it is an area of very high visibility and great emo- 
tional impact, because of its long-term affects on 
morale, welfare and career retention within the Navy. 

I'd like to emphasize what RADM Wilson has said 
this morning about the importance of the planning, 
programming, and budgeting system, because it is that 
train in the Navy which carries an annual allocation of 
dollars to the right places. It moves along at a relatively 
slow pace but, like Japanese trains, it stops for very 
short periods at highly specific times. The window for 
getting aboard is very short. If you don't have a vali- 
dated program, if you can't state your requirement in 
the kind of language that the system understands, or if 
you can't interact effectively within your claimancy, you 
will miss your opportunity for the fiscal year. 

I think one of the biggest legs up on getting this 
problem solved is VADM Arentzen's accession to the 
role of OP-093, which makes him a principal at the 
bargaining table, rather than a claimant working 
through some OPNAV sponsor, as he has in the past. 
He will now be able to compete directly for the dollars, 
and if he is able to defend his program, his ability to get 
the requisite support is dramatically increased. But 
again, if he is not backed up by good data and persua- 



sive arguments, which you must provide, then the 
ability of others to reach into his pocket is also en- 
hanced. 

Finally in response to your final agenda item, I'd like 
to say: Have no fear about rapport and support from the 
general line. We look with great affection on the 
Bureau of Medicine and Surgery and on all the medical 
professionals associated with Navy health care. You 
have the support of everyone in our Navy in the con- 
tinuing improvement in the quality of medical service 
and in providing those facilities which are essential to 
the environment in which you work. Please count on me 
and the OP-090 organization to help in any way possi- 
ble; give us a call. 



Medical Support for the 
Marines 



LGEN Lawrence F. Snowden, USMC 
Chief of Staff, U.S. Marine Corps 



The fundamental issue that I have to take up with you 
at this time is medical care for our combat Marines, I 
focus my remarks on combat Marines because that is 
the focus the Commandant and all of us in Washington 
have toward our Corps. 

You know, we say that the key to the Marine Corps' 
success is the young Marine with a rifle in his hand, 
who is commanded to go seize a piece of real estate, 
hold it, and — hopefully — survive. Now having charged 
him to do that, we certainly owe him the kind of support 
that says: If you are wounded in accomplishing your 
task, we are going to take care of you. We are going to 
ensure that you return to your unit quickly, if possible, 
and if that's not feasible, we're going to ensure that you 
get the best medical care possible, in order that you (1) 
survive as an individual, and (2) continue service as a 
Marine — and most of them want that. 

I found out the other day, as I researched some sta- 
tistics about veterans for a speech, that if you go back 
through all the wars since the birth of our nation, you 
find that 45 million Americans have become veterans 
through military service. Of those 45 million, 30 million 
are still alive — including some 295 veterans of the 
Spanish-American War who are still around, at an 
average age of 98. 

The Veterans Administration will spend this year 
$5.8 billion in medical support of our living veterans — 
SI. 8 billion more than the Marine Corps budget for 
1979. That is a lot of money for veterans' care. And 
despite the fact that it is the general responsibility of 
the VA, I know that it still holds problems for you, be- 
cause of the number of our retirees who are veterans 
but who still look to you, as the Navy support for the 



8 



U.S. Navy Medicine 



Marine Corps, for help with their medical problems. 

Now, I am sure that you wouldn't want to debate 
about whether this country might go to war any time 
soon over some "foolishness" — which is now given as 
the reason why we went to Vietnam. The fact is, in my 
role as a Marine general officer since 1968, I have been 
saying that I don't think the United States is going to go 
to war over a political question. The American citizens, 
I think, would not stand for that. 

On the other hand, since 1968 I have been saying — 
and I am convinced of it — that the greatest potential for 
conflict in the future lies in the battle for resources that 
we don't have. We cannot survive as a nation with only 
the resources within our borders. You couldn't have 
even a telephone if you had to build it from the re- 
sources available within U.S. borders. 

I am trying to make the point that the United States 
cannot live alone any more. The fact is that there is the 
potential, whether we like it or not, for competition over 
resources. 

Combat readiness. Let's recognize that the Marines' 
position in all this is that we don't know what is going to 
happen out there, but we have got to be prepared to go 
wherever ordered, against whomever, whenever called 
— and do it quickly. Therefore, we have to maintain a 
high state of combat capability. 

From the standpoint of the force-readiness position 
of the Marine Corps today, we are at the highest peace- 
time level ever, with our units ready to go to war — and 
do it instantly — and win. 

Now, having said that, I will quote to you a portion of 
a letter from LGEN Les Brown, who retired as Fleet 
Marine Corps Pacific Commanding General on 1 
October 1978. In his closing days, he wrote to the Com- 
mandant: "Mass casualty handling has cost me many 
hours of sleep. If there is an area where we have let the 
young Marine down, it might be here. I have pulled no 
punches in telling anyone who can help us about this 
problem. If there is one thing that could do irreparable 
damage to this Corps of ours, which claims to look after 
its own, it would be the loss of young Marine lives be- 
cause we don't have the wherewithal to treat 
them. . . ." 

I wrote a response for the Commandant to Les 
Brown, assured him of our concern, and assured him 
that we would continue to work on the problem. But I 
don't — as you don't — have an immediate answer to 
give him and make him fee! exactly comfortable. 

The primary message I want to discuss with you this 
morning is the importance of our working together to do 
two things. One is to remember, in all the problems 
that beset you in looking after the Marine and his de- 
pendents in garrison, that the important thing is to get 
your young medical officers into the field. In particular, 
get them acquainted with the Marine Corps through 
service to the Corps — service in the field — and let them 
recognize that their concerns for the Corps are not 
limited to the regional medical center approach. The 



fundamental task centers on that Marine in the field, 
and that somehow has to come first. 

You've heard the old saw that it is very difficult to 
keep your eye on the mission of draining the swamp 
when you are up to your waistline in alligators. Well, 
the alligators that are snapping at you come from the 
Marine when he is in garrison — from the concerns he 
has over your treatment of his wife, your treatment of 
his child. That gets to be a particularly terrible problem 
for him (whether it is real or just perceived) when he is 
in the field, undergoing training, and is separated from 
them, and he gets a letter from home that says his child 
is not being adequately taken care of. Now maybe the 
mother just doesn't understand; maybe the child 
doesn't need what she thinks he needs. But that is a 
problem you and 1 have to deal with, if it is a perception 
in the mind of that Marine and his family. 

But while I want every dependent and every wife and 
every child to be attended to in the way they'd like to be 
attended to, there is a more fundamental problem I 
want you to think about. The fundamental support that 
we have got to have for the Corps must center on that 
Marine in the field, who is going to fight when the chips 
are down. We must ensure that he can survive, if pos- 
sible, and continue to be an asset to the Corps in that 
military action. 

I know that you are concerned here with the manage- 
ment of resources, management of personnel, and 
OPNAV and Bureau relationships. I have no hope that I 
could add anything to your agenda that says: "Put 
aside some of those and center on how you are going to 
provide support to that Marine in the field." But it is a 
thread that I must ask you to weave through all of these 
topics. 

While you are worrying about the resources at the 
regional medical center, remember that the Marines in 
the field don't get to the medical center. Oh, they get 
there eventually, of course, but initially they have to be 
treated in the field, where the accident potential is high 
in peacetime — from artillery shells that go wrong; 
bombs that drop in the wrong place; whatever. The 
potential for terrible kinds of accidents in the field is 
very high in a peacetime environment, when we are so 
intent on our training. 

Operational experience. 1 suspect that some of you 
here have served with the Corps and were pleased 
about it. I will acknowledge that there may have been 
some who have served with the Corps and were not 
pleased about it. We don't expect everybody to like the 
Corps, but more do than don't, I am happy to say. 

The point is that it is important for you, as the senior 
medical members of your community, to help us get the 
idea across to the younger members — your subordi- 
nates, the younger medical officers — that service with 
the Marine Corps is important to their career as officers 
in your Medical Corps. I would hope you can persuade 
them that service with the Marine Corps in a medical 
capacity is valuable professional education for them — 



Volume 70, February 1979 



9 



that it is a wonderful experience that can't be bought 
any other way — and that they should view it as a plus in 
their career pattern rather than as the result of 
irritating the medical detailer. If the latter is the atti- 
tude they have, they are never going to reach the kind 
of Marine Corps - Navy relationship that characterizes 
everything else about our Navy - Marine Corps team. 
And that team, believe me, is worth a great deal to both 
services. 

There are those who have suggested in recent years 
that the Marine Corps' interest in Europe means that 
the Marine Corps is interested in pulling away from the 
Navy. I categorically deny that, and if you give me the 
name and phone number of anybody who makes the 
charge, I will be glad to talk to him. The fact is that 
there is no way the Marine Corps can proceed and 
survive in the years ahead if we are not a part of the 
Navy - Marine Corps relationship. That is fundamental 
to us, and we guard it jealously. But there is lots of 
room, within that spirit of cooperation and service that 
we render to each other, to be sure that down at the 
lowest levels of the Corps and the medical service, our 
men begin to work on these problems together. 

I would hope you encourage your young officers to be 
eager to serve with the Fleet Marine Force. I know 
there are disappointments in serving at the battalion 
aid station, where they don't see a lot of triage but see 
runny noses, ear problems, sore throats, and bad feet. 
But while they are missing out on that part — and I know 
that is a concern to the medical officers who serve at the 
BAS level — they are at the same time coming as close 
as they can come in peacetime to knowing what kinds of 
problems will confront them when war comes. 

The fact is that the old military guys are getting 
older, and we are losing a lot of great combat 
experience from both our services. We have a large 
number of Marine officers now moving up to the bat- 
talion staff level who have not, in fact, heard a shot 
fired in anger. Well, so what? The fellows who went to 
war in World War I, and many who went in World War 
II and became senior commanders very quickly, had not 
heard a shot fired in anger. They did well, didn't they? 
What's wrong with that? 

Well, what's wrong is that a lot of the things they 
did, and that we have managed to stumble our way 
through, could have been done a lot better if we had 
worked harder at training in fundamentals in the field 
before those events occurred. 

So that's what I'm asking you to do. Let's see what 
we can do to get your young men and mine together in 
the field, to do as much as they can do, in the absence 
of those shots being fired in anger, to know how to 
handle those casualties that come in by the truckload to 
that battalion aid station. That is where, instead of 
having the modern medical facilities that you would like 
to have to operate, you are operating in a tent. And you 
will be operating in a tent if we don't get better support 
through the budget for some of those nice medical 



components and shelters that we keep asking for, and 
asking, and asking. 

Peacetime planning. Now, what are you going to be 
prepared to do if war comes and we are as "bad off" as 
we are now? And I think most of you agree that we are 
"bad off" in many ways — in materiel and in shortages 
of some people. 

Well, that is another part of what we have to concen- 
trate on in peacetime, because the primary function of 
those of us in the military establishment in peacetime is 
to plan for that terrible situation that exists as soon as 
the crisis comes. We have got to be prepared, with 
adequate peacetime planning, for the worst-case situa- 
tion in war. We need the best kind of planning and co- 
operation — from the lowest levels, right up through all 
elements — so that you, at your Navy Surgeon General 
level, and we at the Marine Corps level can say, "These 
are our requirements, now that the chips are down; see 
how fast you can fill them." And those of you who have 
been around at the opening of a conflict know that when 
they finally take the constraints off the system, a lot of 
wonderful things can flow through the pipeline — and 
flow quickly. 

I recognize your peacetime medical problems and 
medical care is important. But I hope there are ways 
that can be provided in addition to getting at what I 
think is most fundamental to our mission — and we 
Marines are mission oriented. Our primary mission, as 
I have said, centers on that young Marine who is out in 
the field with a rifle in his hand, or a machine gun on 
his back, or operating a mortar or an artillery piece. 
And we have got to be sure — as we look to resource 
management and all these problems that beset you at 
the regional medical center level and the Bureau level 
— that you keep in mind our mission orientation, which 
is to get out on the battlefield with that young man and 
win. 

I seize the opportunity this morning to tell you that I 
am appreciative of the support I have personally 
enjoyed from the Medical Corps of the Navy over my 
years as a Marine. I look forward to working with you 
and to having your people work with us at every level of 
the Corps, to ensure that we face mutual problems with 
mutual cooperation, for the benefit of both services. 



Medical Support and the 
Logistician 



VADMT.J. Bigley, USN 

Deputy Chief of Naval Operations (Logistics) 



As you know, I am the Deputy Chief of Naval Opera- 
tions for Logistics, and as such I enjoy a very close 
working relationship with the Surgeon General. 



10 



U.S. Navy Medicine 




* 

-f . 
1 

' - 
* k 


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f\ 




*■< 


^ 




VADM Small 



LGEN Snowden 



m 

VADM Blgley 



Until the recent establishment of the new office of the 
Surgeon General on the OPNAV staff, OP-093, the 
DCNO for Logistics was responsible for day-to-day 
representation of medical issues at the OPNAV level. 
Even with the establishment of the Surgeon General's 
new office, my staff and 1 continue to maintain strong 
ties with the Bureau of Medicine and Surgery, 

At the present time, there are several areas of con- 
cern in logistic support. We recently had a worldwide 
command exercise, known as "Nifty Nugget," that was 
an eye-opener to many people. It pointed out to all of us 
in the logistics field just exactly where our shortcom- 
ings and shortages are. At the same time, it did not 
leave us completely despondent about the future. But 
"Nifty Nugget" is going to be a term that we are all 
going to hear a lot about in the next few months — par- 
ticularly as we approach the new POM process at the 
budget table — in relation to the supportability and sus- 
tainability of our forces. 

When we think of logistics, we normally think of the 
traditional "three B's": beans, bullets, and black oil. 
But you, also, are concerned with logistic support — that 
is, support of the human being. 

There are two programs that are currently on the 
front burner with us in OPNAV. The first is the fleet 
hospital. It has been recognized for some time that we 
do not have adequate fleet support for casualties, in the 
event of a worldwide conflict. 

The second program — to provide an alternate to the 
hospital ship — has come to the fore because of the 
retirement of Sanctuary, the last of our hospital ships. 

These two programs will have a pricetag of approxi- 
mately $300 million. 

The need for the fleet-hospital program was recog- 



nized in 1976. Under the able leadership of RADM Al 
Wilson, the Navy started devising a new form of fleet 
hospital that is basically a combination of containers 
and tents. There has been a callout in the CINCs Opera- 
tional Plans for approximately 12 of these fleet hospi- 
tals. They are not cheap but they are certainly neces- 
sary, and they have been recognized as being a valid 
requirement. 

When we get involved in the POM process for 1981, 
the fleet hospital concept is going to have to compete at 
the budget table. But we in the OP-04 organization 
strongly support it, and 1 am sure we will be able to 
make others realize that it is absolutely essential to get 
started on this program. Indeed, if we are successful, 
we can expect the first fleet hospital to be in inventory 
in FY 1982. 

The second program — an alternate for the hospital 
ship — is a little more complicated and has not been 
clearly defined as yet. Initially, the concept of using 
containerships with containers, configured as hospitals, 
that could also be used ashore — sounds very attractive. 
However, there are problems of functional separation 
with the hospital container units on board a ship. 

We have asked the commander of the Sea Systems 
Command to expedite his study and review of the 
problem. Hopefully, that study will be completed in the 
next few months, and this program, too, will take its 
place in the competition at the budget table. 

One of the things we found out, in the Nifty Nugget 
exercise, is the shortfall in our advanced-base func- 
tional components, the ABFCs. 

Fleet hospitals are part of the advanced-base func- 
tional components, which comprise groupings of 
materiel and equipment required for the performance 



Volume 70, February 1979 



11 



of specific tasks at advanced bases. In the fleet com- 
mander's or the CINC's OPlan, if he states that he is 
going to need an advanced base in some remote corner 
of the world, this is the equipment that is called out to 
provide support at that base. Fleet hospitals could well 
be the type of function the fleet commander wants at a 
particular advanced base. 

In reviewing the fleet commander's plan, we found 
that what he had called out as his requirement far 
exceeds what is currently in the inventory. This is the 
problem: identifying the funds we need in order to be 
able to provide not only the fleet hospitals but also the 
other advanced-base functional components that will be 
required. However, I feel optimistic that — particularly 
as a result of the Nifty Nugget exercise, which has 
pointed out our shortfalls in combat sustainability — we 
will have a very sympathetic ear at the budget table. 

When I think of my past experience in the Navy, pri- 
marily associated with the operating forces, I often 
wonder how I ended up being a logistician. Those of 
you in this room, who have been dealing for many years 
with support of our people, are also logisticians. 

I recently came across a piece, author unknown, 
which describes the logistician, and which 1 thought 
might be of interest to you. It goes like this: 

An ancient historian once wrote a very erudite expose con- 
cerning the logistician and his place under the sun. 

Logisticians are a sad, embittered race of men, very much 
in demand in war, who sink resentfully into obscurity in 
peace. They deal only with facts, but must work for men who 
traffic in theories. They emerge during war because war is 
very much fact. They disappear in peace because, during 
peace, war is mostly theory. 

The people who deal and trade in theories, and who employ 
logisticians in war and ignore them in peace, are generals (or 
admirals). Logisticians hate generals. Generals are a happily 
blessed race who radiate confidence and power. They feed 
only on ambrosia and drink only nectar. In peace they stride 
along confidently and can invade a world simply by sweeping 
their hands grandly over a map. In war they must stride more 
slowly, because each general has a logistician riding on his 
back, and he knows that at any given moment the logistician 
may lean forward and whisper, "No, sir, you can't do that." 

(I found myself in that position during the Nifty Nug- 
get exercise.) 

Romping along beside generals are strategists and tacti- 
cians. Logisticians despise strategists and tacticians. Strate- 
gists and tacticians do not know about logisticians until they 
grow up to be generals — which they usually do — although 
sometimes generals will discipline errant strategists and 
tacticians by telling them about logisticians. This sometimes 
gives strategists and tacticians nightmares, but deep down in 
their hearts they do not really believe the stories, especially if 
the general lets them have an occasional drink of his nectar. 

Sometimes a logistician gets to be a general. In such a case, 
he must associate with generals, whom he hates. He has a 
retinue of strategists and tacticians, whom he despises, and 
on his back is the logistician, whom he fears. That is why 



logisticians who become generals are a fearsome and frus- 
trated group who wish that they were anywhere else. They 
beat their wives, get ulcers, and cannot eat their ambrosia or 
drink their nectar. 

I think that all of us in this room are logisticians, and 
we must be prepared to tell the tacticians and the 
strategists, who may not want to listen, what they can- 
not do. 



Medical Care: The Benefi- 
ciaries' View 

R.W. Nolan 

National Executive Secretary 

Fleet Reserve Association 



As the National Executive Secretary of the Fleet Re- 
serve Association, I'm privileged to represent 142,583 
shipmates and their families of the Navy, Marine 
Corps, and Coast Guard. Of these people, about 30% 
are serving on active duty. The remaining 70% are 
either serving in the Fleet Reserve or fully retired from 
active military service. 

I'd like to stress to you that the views I present to you 
today are not just my views — they're not just based on 
mail I get across my desk. 

A year and a half ago, the Fleet Reserve Association, 
in answer to the President's Commission on Military 
Compensation, formed its own compensation study 
group: the White Hats' Pay Panel. The panel went out 
into the field in seven areas across the nation and held 
public hearings, asking active-duty people to tell us 
their views. 

Also, we have the Navy retirees' seminar program, 
held primarily in October each year. Under this pro- 
gram, the various military commands hold seminars for 

retirees, to inform them and discuss some of their prob- 
lems. 

I have been privileged to attend 60 of these retirees' 
seminars around the country. So that experience, the 
experience we had with the White Hats' Pay Panel, and 
my own job of trying to keep in touch with what people 
are thinking — all these form the basis of what I'm going 
to say about how the military community views military 
medical care. 

The military community — both active-duty and 
retired — views its health care as a rapidly fading bene- 
fit. Military personnel have always considered the mili- 
tary as their "family doctor," but in the last couple of 
years, for various reasons, their family doctor has been 
becoming a nonentity. The care they were led to believe 
they were going to receive is starting to disintegrate, 



12 



U.S. Navy Medicine 



and very rapidly. They are bewildered by a barrage of 
conflicting actions from various sources; they can't 
really figure out whose responsibility it is to make sure 
they get that care. 

Let me cite a few of the conflicting things that are 
happening. Congressional committees (primarily the 
Armed Services Committee) say: "Yes, you are guar- 
anteed care. Of course it's on a space-available basis, 
but we're going to ensure that you get that care. Just 
don't let it cost too much because then, you know, the 
Appropriations Committee gets unhappy." 

Then the military community sees the Appropriations 
Committee take a meat axe to the budget for medical 
care and for CHAMPUS. They hear that the Depart- 
ment of Health, Education and Welfare is trying to 
elbow its way into military medicine. They wonder why 
the Administrations — both Republican and Democratic 
— have placed far more emphasis on hardware than on 
people. 

Of course, they are totally fed up with the red tape 
and bureaucracy of CHAMPUS. And it did not help too 
much when the Secretary of the Navy testified publicly 
that CHAMPUS is "a total disaster." 

Finally, they are really bewildered when they hear: 
"There's going to be a new study made. Everything's 
going to be all right. We're going to take a good look at 
this — we're going to analyze the situation." 

Very frankly, they greet that with derision. They're 
sick of studies. 

The vast majority are disenchanted with the delivery 
of care at military medical facilities. They appreciate 
that there's a doctor shortage, but they're fed up with 
long waits for care and with the unprofessional appear- 
ance and attitude of some medical personnel. This, in a 
nutshell, is what I believe is their view of medical care 
today. 

Now, keep in mind that I'm a beneficiary of health 
care too. My FRA members are beneficiaries of health 
care, and they don't like to admit it but maybe they're a 
little bit of the problem. So let's address these prob- 
lems and think about some of the things we might be 
able to do. 

The very first thing, I believe, is that both the pro- 
viders and the recipients of care must stop resigning 
themselves to the "hopelessness" of the situation. It's 
not a hopeless case — things can be done about it. 

Next, I think we should address ourselves to what we 
can do in-house to improve the situation within the mili- 
tary health care delivery system. The basis for such 
action should be a rational assessment of exactly what's 
going on. We should be a little frank on both sides of 
the street; acknowledge what can be done effectively; 
then set about to do the things we're sure we can do, in 
a positive manner. 

Establishing communication. Commanding officers 
of the military medical facilities, in particular, should 
start establishing a viable communication link with the 
military community. Plans on paper don't work. Plans 



entered into and handed off to somebody as a collateral 
duty don't work. You've got to get involved in the 
project, sink your teeth into it, get a grip, and make 
sure that you tell your side of the story. 

Be ahead of the game. Have that community out 
there knowing that you are making good use of your re- 
sources and understanding why you are changing a 
policy or establishing a new one. 

Make your channels of communication work for you. 
Wherever you have military medical facilities, you've 
got branches of the Fleet Reserve Association, the Navy 
Wives' Club, etc. Bring those people on board. Don't 
just wait until they have some special function and then 
send somebody over to speak to them. Have some- 
body that's knowledgeable go over to a meeting (it 
doesn't have to be the admiral; it doesn't have to be the 
CO of the hospital) and not say anything — just meet the 
members and get their thoughts. Then the next time, 
when he does get up on the platform, he will be wel- 
comed as a part of the community and listened to a little 
better. 

The Fleet Reserve Association has an in-house 
publicity organ, as well as a national magazine. We 
print it ourselves, and it goes to every branch presi- 
dent, every branch secretary, and every branch mem- 
bership chairman, plus other people that each branch 
designates according to its size — maybe a total of 2,500 
people. We have another mailing list that totals about 
3,300 and includes every command, every command 
master chief petty officer in the Navy, every command 
career counselor in the Navy, the command enlisted ad- 
visors of the Coast Guard, and the command sergeant 
majors of the Marine Corps. So we can offer you a 
beautiful opportunity to get the word out to these 
people. We have our own in-house printing; we have a 
multilith press; we cut stencils; and anything that can 
be photographed we can print — we can back you up. 

I'll tell you very frankly that, from where I sit. it's the 
rumors, the half-truths, the misunderstandings that are 
killing us. If you get two-way communications going, 
you're going to save yourselves an awful lot of grief. 

Well, you say, that's going to take a lot of work. 
That's true, but it's going to take a lot more work to get 
things untangled if we keep on going the way we are 
now. 

I can appreciate, very sincerely, the problem that you 
have with the shortage of doctors, staff, etc. I think 
VADM Arentzen can say — as probably others of you 
might — that when I have testified before Congress on 
these issues I have always come to the Surgeon Gener- 
al's office first and gotten that side of the story. In fact, 
the largest share of our success as an organization has 
been gained because the Navy, the Marine Corps, and 
the Coast Guard cooperate with us and give us good in- 
formation on which to base our assessments. 

With this information we can assist you in many, 
many ways — on Capitol Hill, in the Pentagon, in the 
military establishment, and in the military community. 



Volume 70, February 1979 



13 



We can educate the beneficiaries of the health care 
system in the ways we must use the resources we have 
at hand, and we can explain to them the things that are 
going to have to change. 

One example is the case of the physician's assistants 
and extenders of care. It doesn't give our active-duty or 
retired personnel much of a problem to have a physi- 
cian's assistant help us. (I served on a destroyer where 
we had a corpsman second class, and we were doggone 
happy to have him. We had complete faith in him — no- 
body ever questioned it.) But maybe our dependents 
are not going to have that kind of faith. So we need to 
get that across to them, and to explain that we've got to 
make the best use of our resources. 

I sincerely believe it is going to be a long, long time 
— by that I mean a few years — before the Administra- 
tion and the Congress get fully educated on health care 
as we would like to see it. But you can rest assured that 
the Fleet Reserve Association is going to do its very 
best to make that happen as soon as possible, including 
drawing on your expertise to help. 

Meanwhile, we're going to have to improve things in- 
house. The services individually — the Navy, the Marine 
Corps, the Army, and the Air Force — are going to have 
to get their acts together, so that the people on the Hill 
don't divide and conquer. 

You must also remember that a national health care 
program is right on the horizon. It's going to be a while, 
because it's going to be expensive as the devil, as we all 
know. But nevertheless it's there. And I believe you 
will agree with me that if and when that happens, the 
military community is going to lose the broad range of 
benefits under CHAMPUS. I can't envision the U.S. 
Government adopting a national health care program 
and operating it over here while running CHAMPUS 
over there for the military. 

Very frankly, from a selfish standpoint I don't think 
any of our members of the FRA are looking forward to a 
national health care program. But if we can get our acts 
together, I think that we can make our case much more 
forcefully to prevent a loss of benefits. 

Only in this manner can we reach the ultimate goal of 
returning to the concept where the military is truly the 
military community's family doctor. 



Learning to Communicate 



RADMD.M. Cooney, USN 
Chief of Information 



I think we have a communications problem on our 
hands. You've all gotten chewed out a little bit by Bob 
Nolan. It was a friendly chewing out, but I think the 
message there is that doctors these days really have got 
to be dedicated medical professionals. 

14 



About five years ago, everyone was running around 
being "involved." They had to be "involved" with one 
another; they had to be "involved" with their jobs; they 
had to be "involved" with their associations. And now 
the Chief of Information comes along and tells doctors, 
dentists, and other medical professionals that they have 
to be "dedicated." 

What's the difference between "involved" and 
"dedicated"? 

Well, I just ask you to reflect on breakfast. We had 
ham and eggs. The lesson is there: the hen was in- 
volved, but the pig was dedicated. 

I'm not asking you to lie down in front of the butcher 
and get sliced up. But I am saying that we are dealing 
in an environment that is difficult for us all. It would be 
very easy for you, as medical professionals, to say: 
"Gosh, everybody criticizes me. I am being singled out 
for attack. Yet no one is coming around with a list of 
names of new doctors or new nurses, or a large blank 
check for the money to construct new medical facilities 
or buy equipment and drugs." 

You might feel a little bit like the Lone Ranger as a 
result of these messages being communicated to you. 
Don 't. The entire Navy, and indeed most of the major 
institutions that comprise American society today, are 
being targeted with exactly the same type of skeptical 
evaluation. 

While being aware of the fact that you are not alone 
in this pursuit of your faults doesn't necessarily make 
you feel as appreciated as you might, and doesn't sug- 
gest any immediate solutions to your problems, I think 
that it can help you keep the whole issue in balance so 
that you don't say to yourselves — either consciously or 
unconsciously — "Everything I do is wrong, so I guess I 
won't do anything." That could very well be a normal 
human reaction to what you could perceive as a lot of 
unfair criticism aimed directly and specifically at you. 

Now it is true that criticism of Navy medical care 
tends to be intense because the people who are seeking 
it don't feel well for one reason or another. You know 
that a lot better than I. But let's put it into perspective. 

Our nation began as a small unit of society: the pil- 
grim village, the pioneer town. All our associations 
were centered around the home, the church, and the 
immediate community — where common interests were 
well established and well known, and interpersonal 
communication was easy. It was all conducted on a 
face-to-face basis. 

But this isn't the 1600s any more. Trace the develop- 
ment of that simple pilgrim society through the 1600s, 
the 1700s, the 1800s, the 1900s, and we see that every- 
thing has gotten bigger, and all the aspects of our 
society have gotten more complex as they have grown. 
It is no longer possible to deal with the gut issues that 
hold our society together on a town-meeting, face-to- 
face basis. So we have created social organisms to take 
care of many of the problems which we used to deal 
with ourselves. We call those social organisms ' 'institu- 

U.S. Navy Medicine 




Eleven workshops at the conference tackled assigned topics to develop policy recommendations. 



tions." We have financial institutions, educational in- 
stitutions, medical institutions; we have social institu- 
tions, welfare institutions, governmental institutions. 

What is the public attitude toward institutions? It is 
what I have described to you: overcritical skepticism. 
We see that the institutions people are most skeptical 
about are the largest. And the largest of the institutions 
in the country is the government. The Watergate inci- 
dents accelerated that attitude of critical skepticism 
toward government — let's face it. People started look- 
ing around and saying: "Can we believe the White 
House? Can we believe the Congress? How did we get 
into this situation?" 

And within government — next to HEW, with which 
you are somewhat involved — who has the biggest 
chunk of dollars to spend, and who has the largest pay- 
roll? The Department of Defense. And within the De- 
partment of Defense, whose budget is the largest? Who 
is the largest employer of people, and who has the most 
difficult mission to explain? The Navy Department. 

So we, wearing the blue and gold, find ourselves 
members of the institution to which perhaps the largest 
amount of dollar-oriented, social-oriented skepticism is 
currently being addressed by our society. 

You, as doctors within the society, have your own 
special problems, because that skepticism comes not 
only from the outside but from the inside as well. And 
at the same time that this attitude is being generated 
toward us as naval officers, it is being generated toward 
you and your civilian counterparts because the institu- 



tion of mass medicine is also open to the same broad 
general attitude of skepticism on the part of the public 
as a whole. So you are two-time losers, and you haven't 
even started the race yet. Congratulations! 

You say, "Hey, he told me that I've got a problem 
and everybody else has a problem — I guess there's no 
solution." 

That's not true. There is a solution. 

'Image' vs. 'reputation. 1 Now, I'm going to talk to 
you about some basic rules of communication. The first 
thing that we have to be aware of, if we are going to be 
effective in communicating, is that there is a difference 
between "reputation" and "image." 

We hear a lot of people talking about "image." The 
politician wants a "good image." You think you want a 
"good image" for your hospital. 

What's the "image" of a hospital? 1 can create an 
"image" of Bethesda by showing a slide on a screen. 
An image is something that is artificial and created. 
You don't really care about images. You're not in the 
"image" business. 

Let me give you a better illustration of that. I see this 
fine handsome young doctor sitting here — do you think 
we could turn him into a sex symbol? I think I could. If I 
had $100,000 to spend, I would rent him a nice Rolls 
Royce, buy him a sharp set of threads, subsidize him to 
be seen around town with the right female jet setters, 
and finally get him a date with a major sex symbol. So 
finally, on that Saturday night, his image too would be 
that of a sex symbol. But what would his reputation be 



Volume 70, February 1979 



15 



on Sunday morning? We'd really have to ask this super 
star because reputations are based on demonstrated 
performance. 

I don't want you to think in terms of "image," be- 
cause that will make you paint buildings that are 
cracked, have corpsmen shining shoes when they 
should be going to school, and doing a lot of other 
things to put up appearances. 

My basic philosophy on this is that an institution's 
reputation will never be as good as its performance. In 
other words, we are always going to lag behind. But the 
difference between our reputation and our performance 
is an effective measure of our communications pro- 
gram, because we not only have to do things well, but 
we have to tell people that we're doing them well. 

The other rule I want to throw at you is that com- 
municating without planning may let you stay even, but 
it will never help you win. If you sit around and wait 
until the patient dies in the waiting room to Figure out 
how you are going to explain it, you may get out of it all 
right, but you will not have the advantage of being able 
to explain to someone how — if you'd had the proper 
equipment or proper whatever — the patient might be 
alive today. 

That is an extreme example, and I probably should 
have used a lighter one. But my point is the same one 
you heard from the preceding speaker, Bob Nolan: 
You're not telling people the things they need to know 
in order to be good patients. I'm sure other people have 
told you the same thing, either face-to-face or indirect- 
ly, or we wouldn't be having this conversation now. 

What you must do is say, "I've got to have my 
reputation solidly backed by an effective communica- 
tions program — based on planning — so that my staff, 
my patients, and my potential patients in the 
community will know, really, who I am, what I do, what 
my capabilities are, and what my capabilities are not — 
and why." 

The message and the medium. That brings us to the 
first step of the communications equation: You have to 
figure out what it is you want to tell people. 

The next question to ask yourself is, Who is it that 
you want to tell? 

After you Figure out what your message is and who 
your audience is, you must then decide what medium of 
communication is the most effective way to get this 
message to that audience. 

Let's very quickly analyze the audiences. Who are 
they? They are: the active duty officers and enlisted 
personnel within your general area of responsibility, 
and their dependents; the retired personnel in your 
area and their dependents; and that very, very impor- 
tant special audience — the people who work for you, 
and their dependents. For all of them, you may have 
the same basic message, somewhat modified to accom- 
modate their own unique, special interests. 

So, in communicating, you are: 

• defining the message; 



• identifying the audience; 

• modifying the message; 

• figuring out the best medium to get it to the audi- 
ence; 

• transmitting the message via the preferred me- 
dium; and 

• measuring to ensure receipt of the message. 
Anybody will tell you that the most effective way to 

communicate is face-to-face. Get people in, talk to 
them, and answer their questions. But if you are deal- 
ing with an audience of several thousand people, as 
most of you are, that isn't very cost effective. So you 
have to fall back on the mass media of communication, 
through which you talk to thousands of people at the 
same time. And here you've got options. 

You've got the print media — your hospital news- 
paper, the Plan of the Day, the bulletin board, special 
pamphlets — anything you think is needed to address 
the issue. 

You've got the electronic media. If you're overseas, 
you can use Armed Forces Radio and Television. If you 
don't have that, it is possible to use tape recorders for 
both sound and video. 

Finally, you have face-to-face communication in 
which you may not be personally involved, but in which 
members of your staff represent your command and the 
Navy. 

Feedback. We also need to talk a little bit about what 
Bob Nolan mentioned earlier: feedback. You must 
maintain a two-way communications system, because 
you may be transmitting blue and the audience may be 
receiving green. 

The only way you can know whether or not your mes- 
sage is being received in the way you designed it is to 
figure out a way to ask people. Put questionnaires in 
your hospital newspaper. Assign the Master Chief the 
responsibility of Finding out what the perceptions of 
your own people are on certain issues. Check with a 
career counselor and see what people on your staff are 
telling him about why they are or are not reenlisting. 
Put a suggestion box near the door of the hospital or the 
dispensary, and leave some blanks and a pencil so that 
people will have something to write on while they are 
thinking. If you have the opportunity, have a Captain's 
Call on a regular basis. 

Tools. CHINFO can provide you with a whole variety 
of materials, including Captain's Call kits and softwear 
in both radio and television for use overseas with 
AFRTS. There is the Newspaper Editors' Service, 
which goes to the editor of your hospital newspaper and 
carries information on current Navy policies and pro- 
grams. There is All Hands. There is Direction maga- 
zine, which is addressed to your public affairs officer — 
and to you, because communication is a command re- 
sponsibility — to tell you better ways to communicate. 
(There is a special supplement volume of Direction 
which combines past issues on community relations, 
internal relations, media relations, and family com- 



16 



U.S. Navy Medicine 




R. Nolan 



RADMCooney 



RADM McDowell 



munication. If you haven't seen it, take a look at it; it 
will give you some ideas about how to proceed.) 

Let's go through the communications equation again. 
First, you define your message: What is it you want 
people to know? Then you identify your audience: Who 
is it that you want to know it? You modify ynur message 
for the particular audience you want to reach; then you 
transmit the message via that medium; and finally 
measure to find out whether or not people have heard 
what you said, and whether they understand it the way 
you want them to. Then you modify the message and its 
transmission, and go through the same cycle all over 
again. 

I'll give you a basic hint that any advertiser will 
verify. When you come to the point where you are so 
sick and tired of hearing your message that you don't 
think you can possibly say it one more time, your lis- 
tener is beginning to perceive — just beginning. 

Remember, this audience with whom you are trying 
to communicate — with whom you are attempting to 
establish a reputation through sound programs of infor- 
mation transfer, in a process called "communication" 
— has several thousand other messages a day being 
aimed at it, many of them from people more skillful in 
the communications process than you are. The listener 
must, in some way, audit all those messages, sort 
through them, establish priorities, and then take 
action. And he is not going to do that unless what you 
have done is planned and properly executed. 

The public affairs officer. I do not expect you, as busy 
as you are and as highly trained as you are in your 
various specialties, to spend all your time in the com- 
munications business. It's time you got yourselves 
some public affairs officers — people who are trained in 

Volume 70, February 1979 



this and who can provide assistance, support, and 
direction; people who can represent you in various 
meetings and seminars and give you the feedback you 
need in order to carry out your programs. 

Now, i can't give you a public affairs officer — the 
number of professional PAOs in the Navy is limited to 
185. But that doesn't mean you cannot have an officer 
on your staff, selected because he has an interest in 
this, who can be sent to the Defense Information 
School; who can receive basic training in communica- 
tions skills; and who can then polish up those communi- 
cations skills by working with a professional public 
affairs officer stationed in the area where you are 
located. 

The 'crisis' situation. Up until now, the program I 
have been talking about is what I would call a "con- 
tinuing developmental program" — something you have 
to do on a regular, day-to-day basis, both internally and 
externally. But in addition to that, we all face that un- 
usual circumstance where there is fire or disaster: 
something that brings national attention to an issue, 
such as we had at Oak Knoll and New Orleans. What do 
you do there? 

You certainly don't turn to a lieutenant junior grade 
Medical Service Corps officer who got out of DINFOS 
last Thursday. That's what my office is for. 

I am ready to provide you with help, support, and 
guidance on relatively short notice. You let me know 
what the problem is, and I will try to sort out the kind of 
help I think you need and tell you where you can get it. 

I have regional offices in Boston, New York, Chicago, 
Los Angeles, Dallas, and Atlanta. They are manned by 
skilled professional information officers who can come 
to you, work with you, and provide you with support 

17 



and assistance for that particular problem. 

They can't come there and run your day-to-day infor- 
mation program for you. But if you become the target of 
the national media and "60 Minutes" wants to see you, 
you will be informed by my office as to whether or not 
these people can come, and whether or not your par- 
ticipation has been approved by the Department of 
Defense. If the answer to those two questions is yes, 
then the team from the national network will be 
escorted by an officer from my office in New York or my 
office in Los Angeles, depending on where the network 
team is coming from. We will then provide you with 
guidance, assistance, and support, and will try to work 
with you to help frame the direction that the coverage 
on that particular show might take. 

So I'm not merely saying, "Hey, you guys have a 
problem," and then walking away from you. But I do 
want to separate the two issues — one that we would call 
the "front page news issue" and the other, that of con- 
tinuing, day-to-day programs. 

If I can ever help you, please call on me. That's what 
we're here for. 



Medicine and the Law 



RADM C.E. McDowell, JAGC, USN 
Judge Advocate General 



I have come here today with the intention of giving 
you something more than the traditional lawyer's 
speech on the problem of medical malpractice suits. 

For example, the typical address on malpractice 
would have me telling you that the number of cases has 
risen by 20%; that the figures involve many millions of 
dollars; and that the largest single recovery involved a 
man who had had both his lower extremities amputated 
erroneously and won millions, even though he didn't 
have a leg to stand on. 

Instead of that kind of speech, 1 am determined to 
speak today on a wider subject: the entire field that may 
be referred to as "medicine and the law." I hope to 
give an overview of the interrelationship of our two 
professions, and to provide you with an appreciation of 
the many opportunities Navy doctors and Navy lawyers 
have to work together toward a common goal — for our 
professions do have many common interests. 

Medical negligence cases are only one area in which 
Navy Medical Department personnel may have contact 
with lawyers and the legal system. Other areas include 
forensic science (the field of endeavor in which scien- 
tific principles are used to provide evidence in civil and 

18 



criminal cases); preventive medicine, which to some 
extent attempts to avoid contact with courts and 
lawyers; mental health programs; child and spouse 
abuse programs; organ transplant programs; and 
others. 

The fact is that ours is a society of law, and no signifi- 
cant endeavor of modern life can be accomplished with- 
out being affected in some way by the legal system. 
Medicine is no exception. Every patient presents cer- 
tain potential legal problems to the health care system. 
Handling these problems, or preventing them before 
they arise, should be a part of total patient care. Let me 
give you a few examples. 

On a daily basis, in intensive care units throughout 
the Navy, patients approach death in a comatose state. 
As this happens, the issue of brain death often arises. 
Those half dozen or so medical centers lucky enough to 
have a Navy judge advocate attached are able to consult 
with their attorneys concerning their state's definition 
of "death" and can summon the attorney for bedside 
legal consultation. 

Similarly, if a patient is awake and alert, a will may 
be desired, and the medical staff may serve as 
witnesses of mental capacity when the lawyer prepares 
the document. 

If no judge advocate is assigned to your facility, these 
functions may require coordination from the nearest 
Navy Legal Service Office by telephone. But the point is 
that, through the combined efforts of the Medical and 
Legal Departments, total patient care is achieved. 

Medicine and law interact in the emergency room of 
your medical facility. For example, assault victim cases 
should be reported to local authorities for investigation, 
and rape victims should be seen by trained personnel 
skilled in ministering to their needs and preventing 
further psychic trauma. 

1 know that VADM Arentzen and the entire Navy 
Medical Department are extremely interested, as we in 
the JAG Corps are, in a program of care and comfort for 
the rape victim. A reporting and prevention program is 
available in Navy hospitals and in most civilian com- 
munities to deal with cases of suspected child abuse. 

Physicians and lawyers alike have a duty to report all 
these types of cases to appropriate officials and to co- 
operate with local authorities as the legal case pro- 
gresses. Again, total patient care is achieved when 
medicine and law interact. 

Medicine and law interact also in the forensic con- 
text. For example, dentists play an extremely important 
role in providing records and performing examinations 
to identify unknown human remains. This type of 
practice may rarely be encountered in the Navy, but it 
is important that we all be aware of the potential need 
to help — in such times as natural disasters, airplane 
crashes, and the like — to identify remains that are un- 
recognizable from outward appearances. 

Likewise, routine tests run for medical treatment 
purposes may play an important role in a forensic con- 

U.S. Navy Medicine 



text. Reports of blood screens or blood alcohol levels 
have obvious value in criminal or civil litigation, and 
physicians and technicians may be called to testify, to 
explain how those studies were performed and what the 
results may mean. 

Finally, coroners and medical examiners play an im- 
portant role in the forensic context. Medical personnel 
in the clinical studies should be aware of the need and 
opportunity for cooperating with these officials. 

A very "hot" area that involves interaction of law 
and medicine is the subject of asbestos and its related 
health problems. I know there aren't many of you who 
haven't already heard of HEW Secretary Califano's 
announcement of a very serious situation involving the 
health of many Americans: the problem of disease 
related to exposure to asbestos. You know as well as 1 
do that this exposure may contribute significantly to 
various respiratory diseases, including carcinoma and 
others, and that the exposure may occur as much as 30 
years before the disease manifests itself. This has be- 
come a potential medical and legal nightmare, and 
preventive medicine people and others are taking 
strong measures to ensure that unnecessary exposure 
to asbestos is eliminated. Here again, the law and 
medicine work hand in hand. 

I hope these examples of your profession and mine 
working together toward a common end will help you to 
foster an awareness, throughout Navy medicine, of the 
significant contribution we can make to each other's 
mission. Recognizing this potential for cooperation and 
mutual assistance is the first step toward real communi- 
cation between us. 

Malpractice. Earlier, I told you that I wasn't going to 
give the traditional lawyer's talk on malpractice; I 
wanted to talk about something more. Well, as you 
might suspect, I can't entirely resist the urge to men- 
tion medical malpractice. I want to give you a brief up- 
date on the problem, as we see it from the defense 
standpoint. 

Last year my predecessor, RADM Dusty Miller, cited 
to a similar gathering some statistics on the total num- 
ber and dollar amount of malpractice claims in the 
Navy. I regret to report that, as you may have sus- 
pected, the figures are even larger this year. We cur- 
rently have about 175 administrative claims and 125 law 
suits involving allegations of a medical nature — medi- 
cal malpractice. The total amount claimed approaches 
$400 million. 

(Incidentally, this does not include the asbestos 
claims. Believe me, that total goes up every day, and is 
currently over $2 billion. But 1 mention this only as an 
aside. These asbestos claims and suits are not really a 
medical malpractice problem, and on the legal side we 
do not believe that we are liable for these claims any- 
way.) 

The two largest claims settled recently involved the 
death of young mothers. Each left a husband and two 
children. One case involved the mother's death, im- 



mediately after she gave birth to the second child, and 
was settled for $120,000. The other involved treatment 
for kidney disease and was settled for $350,000. In both 
cases, negligence was rather clear. 

Another case pending in the office may soon be 
settled for figures between half a million and a million 
dollars, by setting up a trust for the use of a severely 
brain-damaged child who suffered fetal anoxia during 
childbirth. Again, negligence is clear. 

I don't mean to indicate from these examples that my 
claims attorney assumes negligence in every case. We 
find that about 25% of the claims we see have some 
substantial merit to them. These cases are almost 
always settled. Another 25% of the claims we see are 
clearly without any merit whatsoever and are quickly 
denied. 

That leaves about half the cases, where expert opin- 
ions can be found to support either position. In these 
cases, reasonable small settlements are often at- 
tempted, in order to avoid the possibility of an ex- 
tremely large verdict at trial. These settlements are 
always made without any admission of fault on the part 
of the United States or any individual doctor, and they 
should not be taken as such. 

I want to point out that even though two of the three 
examples I gave a minute ago involved obstetrics, I do 
not mean to imply at all that obstetricians are less 
competent or more negligent than other specialists. We 
find that our cases involve pediatrics, surgery, internal 
medicine, and OB-GYN about equally. The prominence 
of OB-GYN cases probably results from the fact that 
this specialty sees dependents almost exclusively, 
whereas the other departments treat active-duty 
personnel who are barred from recovering from the 
government. 

I also want to avoid giving the impression that the 
specialties I have named are the exclusive focus of mal- 
practice cases. They are not. We have had radiology 
cases, pathology cases, lab cases involving mismatched 
blood, and general medical officers' cases. 

Nonphysicians have also been involved. There have 
been nursing cases (mainly for medication errors) and 
physician's assistant cases (generally for misdiagnosis 
in the emergency room or misdiagnosis of some serious 
condition that masquerades as a simple malady). And 
there has been at least one dental case for extraction of 
the wrong teeth. 

There have been a few cases involving the use of non- 
clinicians in the emergency room. Because I know this 
is a hot issue, I must add that the number of such cases 
is surprisingly small compared with the amount of 
debate the issue has received, I imagine a major reason 
for this is that nonclinicians are constantly aware of 
their limitations and are eager to consult with a 
specialist when they feel they should. Perhaps there is 
a lesson to be learned there. 

The bottom line on all this is that there is no group of 
doctors, civilian or Navy, that is immune from allega- 



Volume 70, February 1979 



19 



tions of medical negligence. If all this is somewhat de- 
pressing, there is some good news to report. For any 
here who might not have heard, it can now be said that 
while no group is immune from being the subject of 
some claim of negligent care, every Navy doctor, every 
nurse — and, in fact, every health care provider in 
DOD — is immune from personal liability. This is the re- 
sult of passage of the so-called Gonzales Act, through 
which Congress has provided absolute immunity to 
DOD health care personnel acting within the scope of 
their employment. 

If any Navy doctor, nurse, dentist, or health care 
professional becomes a defendant in a case alleging 
professional negligence arising out of performance of 
his or her Navy duties, the U.S. Department of Justice 
will defend him or her, and the United States will pay 
for any judgment that might be rendered. All these 
people need do is get in touch with the closest Navy 
judge advocate, and we will take it from there. 

An ounce of prevention. I wish to close with some 
thoughts on what you medical people would call the 
"pathogenesis" of the malpractice problem and some 
"prophylaxis" we lawyers recommend. 



It is often said, in medical circles, that lawyers are 
the cause of the so-called malpractice crisis. In my 
view, the first cause of the malpractice problem is not 
lawyers; it is bad public relations and bad rapport with 
patients. 

The second cause of the malpractice problem is like- 
wise not lawyers. It is substandard medical care, which 
unfortunately does exist to a small degree. 

The third cause of the malpractice problem, I must 
admit, is lawyers who know a good thing when they see 
one. 

(Incidentally, I want to point out that claims of legal 
malpractice, both in and out of the Navy, are on the up- 
swing. You are not alone. But we have no immunity 
from personal liability as you do.) 

Given this pathogenesis of the problem, here are our 
prophylactic measures, based on our experience in 
defending thousands of cases over the years: 

• Keep good medical records. In most cases, the 
medical record is the witness for the defense. If a case 
goes to trial, the physician usually cannot remember 
what happened and has to rely on the record to recon- 
struct events in the patient's treatment. If the record is 




Plenty of coffee and a sense of humor helped. 

20 



U.S. Navy Medicine 



incomplete or ambiguous, it only lends credence to the 
plaintiff's story, and you can bet that the plaintiff will 
have a version of the case that suits his own viewpoint. 

• Don't make admissions in the record or criticize 
others. We have had one record, for example, in which 
a doctor wrote: "This patient is justifiably upset that 
the diagnosis was so missed in the Eye Clinic . . ." It 
later turned out that the physician who made that entry 
did not know the patient's entire history and admitted 
that had he known it, he would not have made the 
entry. We had experts who swore up and down that the 
care in the Eye Clinic was proper, and that the 
diagnosis could not have been made at that time. But 
with the confession of guilt in the record, the judge 
gave a verdict in favor of the patient. 

• Maintain good rapport with the patient. This re- 
minds me of the old law professor who complained that 
modern law schools teach a lot about the law but don't 
teach people how to "lawyer." I suspect the same may 
be true in med school: one learns a lot of medicine but 
not enough about how to "doctor" — the art of handling 
patients. 

It is not enough to say "maintain better rapport," 
and I do not know how to teach that subtle art, but I do 
know that lack of good rapport — the feeling on the part 
of the patient that the doctor is too busy to level with 
him or that the system is too big to be personal — is a 
major factor in the filing of a lot of frivolous claims. 
That is why I listed "rapport" as the number one item 
on my list of pathogenic factors. Furthermore, a large 
number of claims that would otherwise have been filed 
are averted because good rapport was present through- 
out, and the patient harbored no ill will toward the 
physician or the system. 

If I could emphasize one aspect of physician training 
above all others, it would be this establishment of good 
rapport with patients. I challenge every hospital CO to 
instill this thinking in his young doctors. 

• Consult. Too many times we see claims in which a 
choice of treatment was made without proper consulta- 
tion with specialists in the field. Particularly given the 
regional medical center concept, there is no valid re- 
sponse to the lawyer's question: "Why didn't you con- 
sult with a specialist, doctor?" 

• Keep your patients informed. There is a natural 
human curiosity about things medical, particularly 
when they relate to one's own body. Patients have a 
right to know what you plan to do to them. Keep them 
informed every step along the way, and perhaps they 
will be more forgiving if I ess-th an -perfect results occur. 

In summary, let me say it is my opinion that Navy 
medicine is doing an excellent job. Even considering 
the rise in the number of claims, I believe that your pa- 
tients receive high-quality medical care, comparable to 
that found in the civilian community. Given the man- 
power and budgetary constraints placed upon you, I 
have a hard time figuring out how you do as well as you 
do. 



Operational Planning 

CAPTJ.J. Quinn, MC, USN 
BUM ED Deputy Director of 
Program Planning and Analysis 



I intend to give a brief discussion of operational plan- 
ning and our recent experience in the "Nifty Nugget" 
exercise. 

It is my opinion that the very survival of the Navy 
Medical Department, its proud tradition of service to 
our fighting men, and its illustrious history of "can do" 
is in dire jeopardy. The Navy Medical Department as a 
whole seems to have little, if any, grasp of what support 
to the operating forces means. I would imagine each of 
you has your own concept of exactly what that means, 
and each concept is probably different. 

Let me briefly define our concept of support for you. 
We exist for only one purpose — to go to war on a mo- 
ment's notice. Any health care system in this country 
can do what we do in peacetime. The DOD health care 
system, however — and specifically the Navy Medical 
Department — exists to sustain our fighting forces at sea 
and in the field, and we must move rapidly when the 
call comes for service to the fleet and the FMF. No 
other health care system can or will do that. Kaiser- 
Permanente does not deploy. 

In large measure, the combat sustainability of our 
naval forces depends on our readiness to deploy with 
them and to return to duty as many personnel as possi- 
ble. We must do our thing in theater; if the wounded 
are sent home, we probably can't get them back. There 
is not sufficient lift capability in airplanes and ships, 
and there are no replacements in manpower. Of course, 
those unable to mend quickly will be sent home. 

Our mission, then, is clear. It is the conservation of 
manpower. Inherent in that mission is the restoration of 
functional health, the return to duty of as many as pos- 
sible, and the minimizing of disability. 

To accomplish those objectives, we must be capable 
of rapid response, mobility, and flexibility. To achieve 
our objectives, to support the operating forces, a 
smooth transition from a peacetime to a wartime con- 
figuration is required. 

The Medical Department is divided into three major 
systems, each contributing to our wartime mission. 
Briefly, these systems are the CONUS health care re- 
source base (the medical and dental centers); the over- 
seas nontheater medical support system; and the 
theater of operations, or the operating forces. 

As our guide for war planning, we have the Secretary 
of Defense's Consolidated Guidance, which states quite 
categorically that "we will size the peacetime Medical 
Department according to wartime needs, utilizing the 
total force concept" — that is, the active force, the Re- 
serves, and the civilian resource base. 

Gentlemen, this is not a game. We have recently 



Volume 70, February 1979 



21 



completed a major exercise, testing whether our system 
can accomplish its mobilization mission or whether our 
naval forces, sailors and Marines, must go into war 
without us. I'm afraid that, if this exercise was a true 
indicator, the next Marine to yell "Corpsman upl" will 
not get any response. Scandalous, perhaps, but we are 
failing to meet our mission. 

There are many contributing and responsible factors, 
but we are not here to determine who shot John. We 
want to know why John was shot; and the next time he 
gets shot, we want to mend his poor, torn body. 

We attempted to augment three Marine amphibious 
forces during Nifty Nugget. To augment, for those of 
you who do not know, means to bring Marines from 
reduced peacetime, in-garrison strength to full war 
fighting posture. 

As all of you do know, the Marines think long and 
hard about going anywhere without medical support. 
This is a tribute to the Navy Medical Department, and I 
do not mean it as a demeaning statement about the 
Marines. This time, at least on paper, they headed to 
war without us. We didn't get our support there before 
they left. Even if our support had arrived, it wouldn't 
have been in the mix desired. There were too few of 
everything. The rapings we've received at the hands of 
budget decrements and under the weight of shore 
establishment realignment, coupled with the kiss of the 
all-volunteer force, have reduced our ability to respond. 

Did you all know we don't own any Reserves? We 
don't. The Chief of Naval Reserve owns them. Wc don't 
know who or where they are. We tried using them with 
no success. We had no active troops and no Reserves; 
therefore, no mission. 

Nifty Nugget was definitely tarnished gold, but tar- 
nish can be removed. We have programs, we have 
representation, and we have all of you. We will take 
care of the programs and, together with OP-093, we will 
provide the representation. But you must manage our 
resources. 

The critical element. Yours is the critical element. 
You have the folks and, like it or not, those are the folks 
that carry our banner to war. In part, your effectiveness 
as commanding officers will be measured — you can 
expect this to gain much more emphasis from now on — 
by the mobility, flexibility, and readiness of your 
personnel. You see to their care and feeding, training 
and maintenance during peacetime. But when we say to 
you, "We have a war; let's go," your response is 
critical. It can't be: "We are too busy." 

I know the complexities of that. You must expand to 
receive returnees — and that is true in some cases. But, 
depending on the conflict, you might discover that the 
only people left at your facility are the gate guard and 
the housekeeper. 

Ask yourself right now how fast you could draw down 
to that level. Where could your patients go? 

These are the elements of your readiness. How many 
of your support special teams are ready — physically, 



materially, and medically knowledgeable of the role 
they must play in wartime? A pain in the backside, 
aren't they? You're overburdened with dependents, 
retirees, and the like. Why bug you with "maybe" 
problems? 

The chief of surgery nags you to death about the sur- 
gical teams, doesn't he? You're "destroying his service 
by all this Mickey Mouse," or some similar statement. 
Yet these teams and their blocks represent an essential 
element of our operational support. Are these blocks 
ready to go? Have they been inventoried? Would you 
want to be sent to some exotic area where the tempera- 
ture is zero or less with this gear? Did you listen to the 
anesthesiologist's complaint about the drugs and 
equipment? Did you raise a complaint with anyone 
about it? 

If your responses are not positive, then you are not 
supporting the Medical Department or the Navy, re- 
gardless of the quality of care at your hospital. This is 
heavy stuff. It is not cowboys-and-Indians played by 
children. 

We have confused you, I am sure, in the past 
exercise. You have been required to assemble a lot of 
data, very quickly, to support a "war" cooked up by the 
Bureau, while trying to carry out work as usual. Rough, 
and we knew it. And we appreciated your problems. 

The folks that pay our bills— SECDEF, CNO, the 
fleet CINCs — have requirements. If we don't respond 
to them, why should they pay our bills? Gentlemen, we 
must meet their requirements. 

We have the opportunity at this conference to discuss 
our problems and seek some solutions. We need your 
help. 

It is truly my belief that if your staffs are materially 
and mentally prepared to support a wartime mission, 
they can and will give better peacetime care also. This 
is the real world, and these are the problems we face. 



Concerns of the Enlisted 
Community 



HMCM H.A. Olszak, USN 
Force Master Chief, BUMED 



I have been asked to bring to your attention the con- 
cerns of the enlisted community. I could say that we 
share with you common concern in areas such as the 
proposed pay and retirement package, the long list of 
benefit erosions, etc., and let it go at that. To do so, 
however, would be a copout, for there are specific con- 
cerns that are of importance to the enlisted community 
of the Medical Department as well as the Navy enlisted 
community overall. 



22 



U.S. Navy Medicine 




CAPT Quinn 



HON. Edward Hidalgo 



VADM Baldwin 



Some concerns may be perceived; some factual. They 
do, however, surface quite frequently in my travels. Let 
me share them with you. But first let me say at the 
outset that 1 am not here to point a finger or sit in judg- 
ment. Rather, I apprise you of these concerns with the 
hope that your awareness will cultivate support for 
change. 

Housing. Let's start with a basic human need, that of 
adequate housing. We, as the Navy medical commu- 
nity, have over the past few years built many fine new 
patient care facilities. Marring the sites of many of 
these new facilities are those wornout eyesores that we 
call * 'bachelor enlisted quarters." Substandard facili- 
ties, inadequate facilities, promised or never completed 
self-help projects — all are of major concern to our en- 
listed community. 

Three guidelines on bachelor housing have been 
issued recently that impact on this problem: (1) NAVOP 
140/77, Occupancy Criteria for Assignment to Navy 
Bachelor Housing, which lists priorities of occupancy; 
(2) OPNAVINST 11101.40 of 11 Aug 1978, which lists 
activities with BEQs and BOQs; and (3) NAVOP 
107/78, which lists minimum standards of adequacy 
and allows payment of BAQ if standards cannot be met. 

Ladies and gentlemen, I urge each of you to become 
personally familiar with the contents of these guide- 
lines. I then ask that you assess your needs accordingly 
and present them to BUMED. 1 now plead with 
BUMED to formalize a plan for bachelor housing 
modernization, based upon your needs; to push for 
equal competition with other Navy bachelor housing 
projects under the "Directed Program for Bachelor 
Housing Modernization"; and to seek reclama for those 
"fenced funds" from medical modernization that never 
materialized. 



I ask that you, as commanding officers, take personal 
interest in your BEQs; that you insist on better manage- 
ment (most people assigned are generally castoffs); 
that more of the MS rating be utilized as managers; 
that you seek help from, and utilize the expertise of, the 
BEQ management teams; and that you act positively 
and promptly on their recommendations. 

Dual standards. I am somewhat embarrassed to 
bring the next problem to your attention; however, it 
needs to be addressed. Believe me, I have had many an 
embarrassing encounter with my line colleagues, and I 
am sure you have also with your line counterparts. The 
question often asked is, When is the Medical Depart- 
ment going to join the Navy? 

The reference is, of course, to dual standards — dual 
standards between the Navy and the Medical Depart- 
ment, and dual standards within our medical com- 
mands — dual standards in the area of discipline, 
grooming and personal appearance, weight control, 
and alcohol abuse. 

Our junior enlisted personnel idolize the physicians 
for whom they work. Due to their youth, they are very 
impressionable and tend to follow. Consequently, the 
attitude and bearing of the physician has a tremendous 
impact on the junior enlisted community. 

Many of you may have been directly involved in 
mediating conflict between the command master chief 
or assigned enlisted advisor and a physician, even at 
times a department head, who felt his young enlisted 
personnel were being harassed when told to get a hair- 
cut or improve grooming, because the physician or 
department head felt the issue had no bearing on the 
reason for existing — patient care. Or, I hear the prob- 
lem voiced, "Why get on me when no one gets on 
him?" 



Volume 70, February 1979 



23 



These problems created by faulty attitude are real 
and have a tremendous impact on morale. 

I understand your reluctance in dealing with the 
dual-standards issue; however, we have but one set of 
rules that applies from the CNO on down. I strongly 
suggest that this issue be addressed and resolved dur- 
ing this forum. It would give us a tremendous boost in 
morale and greatly improve our image with the line 
community. 

Education. The young men and women we recruit 
into the Navy medical community have, as a rule, a 
high desire to be trained and to pursue part-time 
academic education. As our staffing drops, I hear the 
concern that chits for advanced schooling are held, or 
that personnel are openly discouraged from applying 
for school. Such an approach has impact on retention 
and long-range impact on the health care team. I ask 
that you monitor this problem for us. 

Some commands are reluctant to consider the indi- 
vidual who requests a standby or trade of duty to attend 
an evening class. I ask that you continually encourage 
the pursuit of academics within your command. 

The Navy enlisted community needs your help in 
getting us more dollars for off-duty education pro- 
grams. I don't refer here to HSETC funds, but rather to 
the funds the Navy allows for the Navy Campus for 
Achievement Program, including programs such as 
high school studies, PACE, tuition assistance, and in- 
structor hire programs. 

The Navy is behind all other services in funding. Just 
listen to these funding comparisons: FY 1976: Army, 
$38 million; Air Force, $9 million; Navy, S2.3 million. 
FY 1977: Army, $64 million. Air Force, $11.5 million; 
Navy, $2.8 million. FY 1978: Army, $71 million; Air 
Force, $12.8 million; Navy $2.9 million. 

En the harshly competitive reality of today's recruit- 
ing market, the "Community College of the Air Force, " 
as it is called, holds a clear and distinct advantage over 
the Navy in offering concrete educational advantages to 
the young recruit. I make you aware of this concern so 
that, in conversations with your line counterparts, your 
voice will be heard in helping us achieve a funding in- 
crease. Without action soon, the programs will die. 

In-service training. I hear a lot of negatives being ap- 
plied to the Hospital Corps "A" School graduate from 
most commands I visit. 

Needless to say, you are well aware of the push to 
shorten classroom time and the crunch on training 
dollars. I do not say that all is well with the curriculum, 
and that change is not needed. 

I look back to my "A" School training, which con- 
sisted of 20 weeks of classroom time, and I often 
wonder if I was any better prepared than today's 
graduate. I do recall, however, two people who instilled 
more in me than any "A" School could have done, and I 
refer of course to my ward medical officer and ward 
nurse. 

Unfortunately, the days of the ward-training concept 

24 



seem to be over. We expect today's graduates to func- 
tion flawlessly in meeting our desires when they report 
to work on day one. 

I remind you that part of the mission of a medical 
center or a hospital is to teach and train, and that also 
means teach and train hospital corpsmen. We must 
overcome the reluctance on the part of the physician 
and the Nurse Corps officer to get involved in positive, 
productive in-service training programs. Many of our 
programs are mere paper exercises. 

I ask that you insist on a continuum of training, an in- 
service training program that is positive and career 
enhancing, and that involves the professional side of 
the house. Attendance must be mandatory; lesson 
plans must be standardized and planned well in ad- 
vance. We must use the talent within our commands to 
enhance the well-being of all those assigned to the 
command. 

Utilization of personnel. Our enlisted women still 
complain of paternalism, and many feel they serve just 
one purpose — that is, to act as standbys. Women in the 
service are here to stay, and in ever-increasing num- 
bers. Your help is needed in breaking this stereotype 
and in providing full utilization, based on capabilities, 
in nontraditional areas. 

Utilization and job satisfaction strike at the very 
reason we have a problem in retention. This cuts across 
all our enlisted pay grades, Navy-wide. As we go about 
"aging the force" — that is, time between advance- 
ments is becoming longer — we need your help in pro- 
viding within your commands new challenges, new 
roles for our enlisted force. Of particular concern is the 
high number of well-trained personnel that we lose at 
the E-5 and E-6 levels, who fall within the 8- to 12-year, 
8- to 14-year service group. 

As we shift to the PASS concept and get out of the 
personnel and secondary administrative functions that 
we have been accustomed to, we must provide a place 
in the patient care setting for those 8425 NEC advanced 
hospital corpsmen who return to us from sea. 

Our senior enlisted personnel at the E-8 and E-9 
levels are in dire need of a management training 
course. Thanks to the progressive leadership of the 
Surgeon General, this program may be on track early 
next year. 

We need your help in identifying billets within your 
commands that our E-8 and E-9 petty officers can fill in 
relation to the new role definitions recently approved by 
the Chief of Naval Operations, and in which they can 
find challenge and job satisfaction. 

Chain of command. Our chain of command must be 
strengthened. You must make it known within your 
command that the petty officer structure starts at the 
E-4 level, not at the E-7 level; that there is a difference 
in how an E-4 and an E-5 are assigned tasks, in com- 
parison with an E-2 and an E-3; that responsibility, 
authority, and accountability go with the pay grade; 
and that your petty officers can count on you for 

U.S. Navy Medicine 



backing when needed. 

I feel that our leadership and chain of command have 
been weakened because we have forgotten that as 
human beings we sometimes fail, and failing is no 
longer acceptable. As a result, the young petty officer, 
when confronted with a problem — afraid of failing and 
unsure of backing by the chain of command — does 
absolutely nothing, and this philosophy continues on up 
the chain until every problem comes to rest in your 
office, rather than being resolved at the lowest possible 
level. Your insistence that your staff assign the right 
petty officer pay grade to the task required, and then 
your pledge of full backing, would do much to rectify 
this situation. 

Evaluations. Enlisted evaluations are continually 
taking on greater importance and, for the most part, are 
poorly handled and get little attention in many of our 
commands. 

The system itself is poor. Depending on pay grade, 
we use three different evaluation sheets and a 
multitude of abbreviations to write an evaluation. 
Without a BUPERS manual at one's side, it is virtually 
impossible to know how to begin writing. 

The problem has been recognized. In fact, a panel of 
fleet and force master chiefs has recommended change 
that ultimately will result in a new, single, simplified 
evaluation sheet. Beginning in early 1979, BUPERS will 
handle and scrutinize enlisted evaluations in the same 
manner as officer fitness reports. 

A major problem is that evaluations are not for- 
warded to BUPERS on time, and that narratives seldom 
support the marks assigned. Your command master 
chief can be a big help to you in this area. Depending on 
the size of your command, he or a group of senior petty 
officers under his direction should review all evalua- 
tions for content. 

Recognition. Recognition and the feeling of belong- 
ing to the team — How can this be accomplished? By 
anything from addressing people by name, to com- 
mending by letter, to spending a few dollars for en- 
listed travel and TAD, to awarding of medals. 

'People' programs. We also voice concern over how 
our traditional "people" programs are handled. 

• Career counselors — Some commands have none; 
some do not have enough to cover the number of people 
assigned. Too many are given the assignment as a 
collateral duty and have no time to serve the enlisted 
staff. In some commands it takes a month or longer to 
get an appointment to talk with the counselor. 

I ask that you review NAVPERS 15878, the Retention 
Team Manual that was issued in October 1977. It gives 
clear guidelines and sets responsibilities on all key 
members of the command. Your help is needed. 

• Housing referral offices — These are generally not 
staffed with quality people. If civilianized, these offices 
are usually the first to face cuts. The offices usually are 
not properly supervised, and referrals to the local com- 
munity are not up-to-date. We need your help. 



• Sponsor program — In many commands, it is totally 
ignored. We need your help. 

• Indoctrination program — This is a very critical 
issue, for First impressions are often lasting; yet in 
many commands very little is being done in this area. 
We need your help. 

Ladies and gentlemen, these are some of the major 
concerns voiced by the enlisted community. I am sure 
the issues addressed are not new. You have heard them 
before, and that is what is of most concern. We have 
been giving lip service, without action, for too long. 

I feel we are at the crossroads. The time for action is 
now. For one thing is certain: the source of supply of 
accessions is very rapidly dwindling. We need to devote 
our attention, our time, and some money today to the 
people who support our mission, for if we don't act 
now, we won't have the people to support the mission 
in the days ahead. 



A Special Role 

The Honorable Edward Hidalgo 
Assistant Secretary of the Navy for 
Manpower, Reserve Affairs, and Logistics 



I think this is the right stage in my life, and the right 
scenario, to make a very, very deep confession to you. 
In the next go-around, what I would like to be is exactly 
what you are — a physician. (I am a frustrated lawyer.) 

I've thought of it very often. There are certain won- 
derful comparisons between your profession and mine. 
Both professions are analytical; they are deductive. In 
both, you need facts before you can move. 

But we lawyers deal with very mundane things. You 
people deal with diagnosis that can save life; with 
surgery that can save life; with those incredible factors 
that make up the human being. 

Your role to me is very special, and therefore I can 
assure you that I have dealt with such of your problems 
as have come before me with the deepest interest and 
the utmost sincerity, and have had wonderful rapport 
with your Surgeon General. 

That's by way of preface. 

The medical care problem seems to be at a very 
severe crossroads. In greater or lesser degrees, the 
three services are being hard put to it to meet their 
ever-so-important responsibilities in this area, and the 
exigencies and shortfalls are not going to have an over- 
night cure. This means that you have to use — and count 
on me for any help I can ever give — your resources to 
the fullest possible measure, and with the greatest 
degree of efficiency. 

In terms of this, I've had the privilege to work closely 
with VADM Arentzen, who took a bold initiative with 



Volume 70, February 1979 



25 



regard to the reorganization of BUMED, supported, as 
you know, by an excellent study by Cresap, McCor- 
mick, and Paget. Not that reorganizations, per se, 
achieve the panacea we search for. But they make it 
viable for us to use our resources more effectively. In 
other words, if we've got the wrong organization, we 
know we can't do it; if we've got the right one, we have 
a chance of doing it. 

This reorganization, as it's planned, should liberate 
the Surgeon General, the Chief of BUMED, to do the 
things that should have top priority, and should locate 
and position everyone for maximum effectiveness. 

Let me just mention briefly a recent voyage that I 
took. I went to Hawaii first; then to Yokosuka, Seoul, 
Okinawa, Subic Bay; then down to Rome to see the 
Sixth Fleet. 

You know, I think all the pessimism we hear about 
resides in Washington. Our overseas commanders and 
men and women don't share this pessimism, thank 
God. Everywhere I went, I got the same message: read- 
iness, very high; morale, very high; reenlistments, very 
high. 

Now just think of the vital role that you play in that 
"morale, very high." It's absolutely key. The skill of 
your endeavors; your empathy and sympathy, and that 
of the people who work with and for you — these things 
are key to the morale of which I speak. 

I came back very strongly impressed with the huge 
responsibilities that our great country has today — with 
its presence everywhere, its might everywhere. 
Whether it's Korea or Japan — whether it's the 20-odd 
thousand Marines on Okinawa and Iwakuni or the Sixth 
Fleet — there's that American umbrella. 

You have every reason to join me in this great sense 
of pride that our country is a great power — a great 
power discharging its responsibilities fervently, effi- 
ciently, and masterfully. 



The Navy Personnel Situation 



VADM R.B. Baldwin, USN 
Chief of Naval Personnel 



I'm going to talk rather broadly about the personnel 
situation in the Navy, rather than just focus on the 
medical/dental health services aspect of things, 
although I recognize your focused interest in that part. 

I think there is a very strong kinship and a necessary 
partnership between what used to be BUPERS, until we 
reorganized — and still is BUPERS, as we understand it 
— and BUMED. Both organizations are very deeply in 
the "people" business, and we must maintain a good, 



cooperative partnership attitude. I think that is more 
important than ever now, when we do not have the 
personnel resources to which, perhaps, we became ac- 
customed in the past. We've got to preserve and grow 
our own, so to speak. 

Let me talk about the front end of our personnel pro- 
gram — recruiting. We're not doing well. We have had 
shortfalls in each of the last 20 months save one — last 
July was the only month in which we made our quota. 
We came in 1,100 short in October. 

Quite clearly, the market is tougher than the 
planners predicted when they put earlier budgets to- 
gether, and we're embarked on a crusade to increase 
recruiter resources. I think that, clearly, is indicated. 

Retention. The middle part of the equation is really 
more worrisome. The reason we're not making our re- 
cruiting numbers, taken in the whole context, is that 
we're not retaining enough and are putting too much 
of a load at the front end for the health of the organiza- 
tion, really. Our second-term retention falls somewhere 
in the 50-60% ballpark when it ought to be in the 70- 
80% ballpark. That gives you an order-of-magnitude 
idea of that sag in the middle of our organization where 
you need your main strength — where you've got some 
time and experience on the job. 

This is a relatively recent happening. Four or five 
years ago, we had retention up in that area, from 
people in that particular age group. It's going down, 
and that's a clear signal to us that we have to do some 
dramatic things to turn the situation around. 

In this regard, you all are a particular part of the 
action. These are people who have been in the force 
long enough to make a career decision, and not enough 
are making it. I just ask you to keep this in mind, in all 
your actions and interactions with people in uniform 
and their families. You are a very big factor in the 
decision they make. 

Compensation. Going to the end of the personnel 
structure — retirement considerations — I'm sure that all 
of you are wondering what is happening to the recom- 
mendations of the President's Commission on Military 
Compensation. It reported out, with much fanfare and 
not too good publicity, last spring. Since that time, 
there has been a lot of interplay between us, the ser- 
vices, and SECNAV in looking at the report and giving 
it particular pushes this way and that way that we think 
would make a good thing out of it. 

We are getting close to a decision point. Just over the 
weekend, ASD Manpower put out a kind of analysis 
paper. They really didn't come down on their recom- 
mendation, but they came to us and clearly want our 
final input as to what kind of system we want. 

Our view of current compensation, looking very prac- 
tically at our service, is that it is not working to the 
degree that it should. We are not attracting enough 
people in recruiting — we can prove that by simply read- 
ing the monthly take — therefore, basic attractiveness is 
not there for the young fellow. 



26 



U.S. Navy Medicine 



The sag in our second-term retention says that there 
is not enough compensation for what we are asking this 
group of people to do. That means we must make more 
compensation visible at an earlier age — do some front 
loading. 

We are not in a position to endorse any plan that has 
as one of its assumptions that it is necessary to save 
money in terms of compensation. We think it would be 
folly for our leadership to say, "Yes, my force can take 
a pay cut," when we are not keeping people in the 
numbers we need. 

So, basically, the CNO and the Secretary are looking 
for a compensation package that is a very highly prob- 
able bet to be more attractive to the full spectrum of 
personnel than the one we have today. They will be 
very surprised if such a package can be generated at 
costs less than the current system. 

The Secretary of Defense has not indicated his pri- 
mary consideration with regard to such a compensation 
package, but I think he will give every thoughtful con- 
sideration to the plan and not act precipitously on this 
subject. 

If nothing else has been established in the back-and- 
forth on this compensation plan, there has been a clear 
realization that the Navy needs more help in the area of 
compensation than do the other services. The Air Force 
clearly has a full structure, and you can understand why 
they are very anxious not to disturb the status quo. The 
Army and the Marine Corps are not in as favorable a 
position as the Air Force, but they do not seem to feel 
shortages in the middle grades quite as severely as we 
do. However, we intend to point out that the Navy's 
needs are of such importance that they deserve special 
attention and this will be our position in the bargaining 
that will take place at all levels of the government as we 
go forward for such things as bonuses and special com- 
pensation for the special needs of the Navy. 

I won't make a prediction as to what will happen on 
the compensation plan, other than to say that your 
Secretary and your CNO will be hanging very tough in 
fighting for a plan that is attractive and will stimulate 
people, rather than one that will turn them off. What- 
ever comes out of this, it's going to take some compli- 
cated legal work in drafting, with a new Congress com- 
ing in — particularly if there is a significant change from 
the current system. 

1 think we'll have a long session with Congress before 
anything really happens. So don't look for something to 
happen overnight, and please calm people down who 
are concerned that the system our people in service 
have gotten used to is going to be changed radically. 
Again, the message has come across loud and clear that 
there is considerable nervousness among people now 
on active duty that they're going to have some changed 
expectations. Those feelings will be respected. 

Women aboard ships. Women in the Navy have got- 
ten a lot of publicity lately because Congress changed 
the law that had very severe restrictions on utilization 



of women in ships. We now have the authority to place 
women aboard ships, with the exception of combatant 
types, and we can in fact place them in combatant types 
for temporary duty periods associated with their assign- 
ments, provided the unit is not projected to go into 
combat at that time. 

Some of the first women are reporting aboard ships 
down in Norfolk, and San Diego ships will follow with 
both officer and enlisted personnel shortly. We'll see 
how this goes. 

We're not involved in a social experiment here — I 
want to make that clear. This is being done for prag- 
matic reasons — to ensure that we are making the best 
use of people available to the Navy in light of the fact 
that we are not now attracting the numbers we would 
like to attract. And being able to do that in the future is 
going to be even tougher as the numbers of people 

diminish because you gentlemen and your predecessors 
have gotten so smart in educating the world to the 
dangers of overpopulation. 

We've gone about this in a careful, thoughtful sort of 
way. 1 think that if everybody acts maturely and re- 
sponsibly, it will turn out to be a beneficial move and 
will give us some flexibility that we have not had. 

Organizational changes. I'd like to talk a little bit 
about my own organization and some organizational 
changes that have taken place just recently. 

The Navy has traditionally had a separation between 
its military personnel and its civilian personnel in terms 
of chain of command. Civilian personnel were formerly 
administered through the Navy Secretariat. Now that 
has been changed to run through the CNO chain of 
command, and what was formerly the Office of Civilian 
Personnel has now migrated into OP-01. 

Another significant change has been the investment 
of considerable responsibility for training, planning, 
and programming in OP-01 . The Chief of Naval Educa- 
tion and Training continues organizationally, but he is 
an executor and not double-hatted also as a planner, 
which in the past put him in an untenable position, in a 
way. 

I've always felt that we went too far when we estab- 
lished CNET in divesting the CNO of some of the re- 
sponsibilities that only he should carry. That responsi- 
bility has now been restored; OP-01 is the overall train- 
ing coordinator in town. We aren't going to try to run 
school houses from Washington, in the old perceived 
command mode, but we certainly are going to try to 
ensure that the CNO's responsibilities of laying out 
training requirements are coordinated and put in 
proper priority here at the headquarters level. 

Those are a few current issues of a general nature 
that 1 wanted to chat with you about. I do have close ties 
with the Surgeon General. As I said, I think both of us 
realize we have inseparable interests in many of the 
things that are going on today. I intend to maintain 
these close ties as time goes along so that we can move 
forward together on issues that affect our people. 



Volume 70, February 1979 



27 



Notes & Announcements 



In memoriam . . . CDR Walter A. Bloedorn, MC, USN 
(Ret.), former Navy physician, and former dean of 
George Washington University's medical school, died 
28 Nov 1978, at age 92. 

Dr. Bloedorn was born in North Platte, Neb., and 
graduated from Creighton University's medical school, 
Omaha, Neb., in 1909. He then joined the U.S. Navy 
Medical Corps and had duty assignments in China, 
Japan, Philippine Islands, and as executive officer and 
consultant in medicine at the Naval Medical School and 
Hospital in Washington, D.C. During World War II, 
Dr. Bloedorn helped establish the Army Special Train- 
ing and Navy V-12 programs for drafted college stu- 
dents. 

By 1916, Dr. Bloedorn had received a bachelor and 
master's degree from George Washington University. 
He joined the university faculty as professor of tropical 
medicine in 1926 and retired from the Navy as com- 
mander in 1928. During his naval career, Dr. Bloedorn 
wrote articles on many subjects including cholera, drug 
addiction, venereal diseases, meningitis, heart studies, 
the annual physical examination, gunshot wounds, 
hysteria, and "The Barbarous Custom of Smoking." 

In 1930, he became professor of medicine and assist- 
ant dean of George Washington University's medical 
school. In 1932, he was named medical director of the 
university's hospital and seven years later became dean 
of the medical school. He held both positions until his 
retirement in 1957. In addition to his hospital and 
medical school work, Dr. Bloedorn had maintained a 
private practice in internal medicine until closing his 
Washington office in mid- 19 70. 

Dr. Bloedorn was president of the Association of 
American Medical Colleges in 1947-1948, and of the 
National Board of Medical Examiners in 1957. He was a 
fellow of the American College of Physicians and a 
diplomate of the American Board of Internal Medicine. 



Dental continuing education cowse . . . The following 
dental continuing education course will be offered in 
May 1979: 



Eleventh Naval District. San Diego. Calif. 
Periodontics 



14-16 May 1979 



Applications should be submitted six weeks before 
the course begins to: Commandant, Eleventh Naval 
District (Code 37), San Diego, Calif. 92132. 



USUHS graduate degree programs . . . The Uniformed 
Services University of the Health Sciences is offering 
accredited graduate degree programs in the basic med- 
ical sciences. 

Master's and doctoral degree programs in anatomy, 
medical physiology, microbiology, pharmacology, and 
physiology are currently open to qualified military and 
civilian applicants. Graduate programs in biochemistry 
and preventive medicine are being developed, with the 
admission of students scheduled for September 1979. 
These programs of study are designed for outstanding 
individuals with a strong commitment to permanent 
careers in the basic medical sciences. 

Deadline for applications for the Fall 1979 semester 
is 1 March 1979. 

Selection of students will be based on undergraduate 
and postgraduate academic records, letters of recom- 
mendation, and results of the Graduate Record Exami- 
nation. Specific graduate studies may impose addi- 
tional requirements for admission. 

Military applicants must obtain the approval and 
sponsorship of their military department and will incur 
an obligation for additional service. 

USUHS graduate programs are intended to foster 
independent scholarship, originality, and competence 
in research, teaching, and professional service. 
Graduate students will serve as teaching and research 
assistants in support of the USUHS School of Medicine. 

Graduate courses will be directed by members of the 
medical school basic sciences faculty and will be con- 
ducted in new laboratories designed to support a wide 
variety of research projects. Special resources include 
high resolution scanning and transmission electron 
microscopes, biohazard containment laboratories, a 
central animal facility, computer support, and a medi- 
cal library. 

The USUHS was established by Congress in 1972 and 
has a current enrollment of 99 medical students. The 
campus is located in Bethesda, Md., adjacent to the 
National Naval Medical Center and the Armed Forces 
Radiobiological Research Institute and close to the 
National Library of Medicine and the National 
Institutes of Health. Various affiliations with these 
institutions and the Walter Reed Army Medical Center 
and the Armed Forces Institute of Pathology, provide 
additional resources to enhance graduate education. 

For further information, write: COL John W. Bullard, 
MSC, USA, Assistant Dean for Graduate Education, 
Uniformed Services University of the Health Sciences, 
4301 Jones Bridge Rd., Bethesda, Md. 20014. 



28 



U.S. Navy Medicine 



BUMED SITREP 



CARDIAC LIFE SUPPORT PROGRAM AT JACKSON- 
VILLE . . . NRMC Jacksonville has launched a drive to 
get all medical and paramedical personnel certified by 
the American Heart Association in advanced cardiac 
life support (ACLS). The regional medical center, which 
already had an active basic cardiac life support pro- 
gram, recently inaugurated a two- day ACLS-provider 
course, for physicians, nurses, physician's assistants, 
and EMTs, taught entirely by Navy personnel. 

The course comprises two days of intensive training 
in use of defibrillators, IV techniques, endotracheal 
intubations, acid-base balance, and recognition and 
treatment of cardiac arrhythmias. It culminates in a 
practical test involving a simulated cardiac arrest. 

The Jacksonville program eventually will provide a 
tiered net, throughout the entire medical region, of 
qualified basic and advanced cardiac life support per- 
sonnel who can respond within minutes to cardiac 
arrests or other acute medical emergencies. 



NEW ORLEANS HOSPITAL LEASED ... The Navy 
has leased the F. Edward Hebert Hospital — formerly 
NRMC New Orleans — to Westbank Medical Service, a 
private corporation that will use the facility to provide 
such services as an OB-GYN clinic, special nursing for 
elderly patients, physical therapy, alcohol rehabilita- 
tion, and care of terminally ill patients. Westbank also 
runs the Jo Ellen Smith Memorial Hospital a couple of 
miles from the former naval regional medical center. 

Under the terms of the lease, the Navy will receive 
$480,000 per year in rent — and more if Westbank's 
revenues from the project rise. The Navy will continue 
to operate its outpatient clinic on the first floor of the 
main hospital building, and retains the right to take 
over the entire hospital in the event of a national emer- 
gency. 



NEWPORT DENTAL CENTER DEDICATED ... The 

new regional dental center at the Naval Education and 
Training Center, Newport, R.I., was officially dedicated 
on 7 Dec 1978. 

The $1.7 million facility, equipped and staffed to pro- 
vide the utmost in modern dental care, includes 17 
dental treatment rooms, a central sterilization room, a 
recovery room, a conference room/library, and admin- 
istrative spaces. Support services include a regional 



prosthetics laboratory, a dental equipment repair unit, 
and a regional supply storeroom. 

In addition to providing complete dental services to 
fleet- and shore-based personnel in the Narragansett 
Bay area, the center is headquarters for all naval dental 
facilities in the northeastern United States. Branch 
clinics are located at the Naval Submarine Base, New 
London, Conn.; the Naval Air Station, South Wey- 
mouth, Mass.; the Naval Air Station, Brunswick, Me.; 
the Naval Security Group Activity, Winter Harbor, 
Me.; the Naval Communications Unit, Cutler, Me.; the 
Naval Shipyard, Portsmouth, N.H.; and the Naval 
Administrative Unit, Scotia, N.Y. 



UNIFORM CHART OF ACCOUNTS SEMINARS . . . 

BUMED representatives recently conducted Uniform 
Chart of Accounts training seminars at San Diego, 
Oakland, Virginia Beach, Great Lakes, and Pensacola. 
The three-day seminars covered a wide variety of UCA 
topics, including the Expense Assignment System and 
automated source data collection. 

Detailed UCA implementation manuals will be pro- 
vided to all activities next month; however, it was felt 
that earlier, detailed exposure to UCA was necessary 
for adequate preparation for the 1 Oct 1979 worldwide 
implementation date. 



CSU GRADUATE EDUCATION PROGRAMS . . . 

Graduate programs in Anatomy, Medical Psychology, 
Microbiology, Pharmacology, and Physiology have 
been approved by the Uniformed Services University of 
the Health Sciences' Board of Regents and are now in 
operation. Graduate programs in Biochemistry and 
Preventive Medicine are now being developed, and 
plans are to admit students to these two programs in 
September of this year. 

USUHS invites qualified applicants who have a 
requirement for this level and type of training. Active- 
duty Uniformed Services personnel who are eligible to 
apply and who are approved and sponsored in graduate 
training by their parent service will be given preference 
in the selection process. Interested individuals should 
contact COL John W. Bullard, Ph.D., MSC, USA, 
Assistant Dean for Graduate Education, USUHS, 4301 
Jones Bridge Rd., Bethesda, Md. 20014. 



Volume 70, February 1979 



ftlt.S.GOYERHHENT PRINTIXE 0FFI C E : I 979- -Z8 I -47 I /I 2 



29 



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